Psychotherapy and Applied Psychology: Conversations with research experts about mental health and psychotherapy for those interested in research, practice, and training
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Psychotherapy and Applied Psychology: Conversations with research experts about mental health and psychotherapy for those interested in research, practice, and training
Rethinking Suicide Prevention Strategies with Dr. Craig Bryan
Part two of Dan's conversation with 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.Summary
Dan and Dr. Bryan discuss a transformative approach to suicide prevention, emphasizing the importance of reframing the concept from merely keeping individuals alive to helping them find a life worth living. Dr. Bryan advocates for a collaborative risk assessment model that prioritizes patient needs and experiences over traditional checklist methods. Dr. Bryan also critiques the effectiveness of hospitalization in preventing suicide, suggesting that it may not address the underlying issues and can sometimes exacerbate the situation.
Special Guest: Dr. Craig Bryan
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[Music] Broadcasting 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 42 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. You find the show useful, be much appreciated if you shared it with someone else who might enjoy it too. Today I could be more excited to welcome back one of the world's authorities on Suicide Prevention. My guest is a trot Gebhardt 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 awards on the American Psychological Association, the Edwin S. Schneidman Award from the American Association of Suicideology, and many others. In this part of our conversation, we discuss several aspects of Suicide Prevention, including reframing Suicide Prevention Goals, creating a life-worth living, reconceptualizing risk assessment, legal considerations in Suicide Prevention, and much more. This episode starts with my guest talking about reframing how we think about Suicide Prevention. So without further ado, it is my pleasure to welcome back my very special guest, Dr. Craig Bryan. What you're getting at there is, I think, sort of a philosophy of Suicide Prevention that I think has emerged within myself over many years, which is to reframe the idea of Suicide Prevention, not as preventing someone from dying or, conversely maintaining or keeping someone alive, but instead helping them to live a good life that's worth living. And so the initial stages of working with someone who is suicidal, especially someone who really doesn't feel like they have a lot of meaning and purpose in life, I do have to kind of take a little bit more of that approach of, I need you to say, alive long enough, first to figure this out. And so would you be willing to kind of join me in this process and perhaps force all the decision for a while? You know, you can always kill yourself later, which is usually pretty provocative statement for Suicide Prevention. You see here from a clinician, but part of this process will be right now keeping you alive because it's going to be really hard to find purpose in meaning if you're not around to actually experience it. And I found that by shifting that philosophy and communicating that to a patient and explaining that the reason why I want to have this conversation and perhaps have this, have you go through this uncomfortable experience of not having access to highly lethal methods, serves the underlying goal and purpose of reducing your personal suffering and finding purpose in meaning in your life, which I have found to be the primary goal that many suicidal people have when they initiate care. A couple of the things that stood out when I was reading your writing about this was one, it was a foregrounding of sort of a client-focused approach, and then sort of, I'm going to, I don't know if I fully mean this, but a backgrounding of suicide prevention. And that doesn't mean to ignore it, but that means that like suicide prevention in service of client-focused care, patient-focused care, rather than, you know, I'm putting 100% of my attention on suicide prevention, that and only that, and that is a means to, that's the end. That's it. If I get there, I win. That's what we're going for. It's like, no, we need to do that first in service of patient-focused care. Yeah, and I think what helped kind of push me to think about the issue in this way, it was really, it's listening to the lived experience of suicide-attempt survivors, of others who have struggled with suicidal thoughts, who have said, you know, don't just keep me alive because my life to me seems unbearable. I'm hurting. And so when you, when you are permanently motivated and you're like telling me, that I need to stay alive, what I'm sheering, the message received is, I need to suffer forever. And that's, you know, from my perspective, so it is like, that's awful. Like, what if that's not a very attractive option you're offering me here? And so, that was something that definitely comes to appreciate over time of saying, okay, let's, let's kind of move away from thinking of suicide prevention is nearly keeping people alive because I think that does also motivate us to use coercive strategies. And to instead say, let's create a life that's worth living, because then we were under suicide obsolete because if you felt like life was good and you were happy and you had purpose, then probably, you know, can't say for sure, but there's a good probability that you wouldn't be experiencing this misery that's driving you towards suicide. And of course, most of our patients are kind of like, yeah, that's exactly right. And so then it's like, okay, so let's talk about how the first step in this process is keeping you alive and long enough for us to get to that point, because I'm not probably not going to be able to solve all the problems today. It's probably not going to be this week or next week either. And so, kind of where are we at? Are we going to work together on this? And I think that that collaboration is just absolutely key. So it's, again, it's kind of like flipping that question, like I said before, it's not why do people die, it's why do people choose to live and by shifting the focus of the question and the idea of suicide prevention away from death towards staying, like living a good life? I think that's just really powerful. One of the other feelings I had reading your work was on this topic was slow down. Like as a clinician, slow down. You know, I think that oftentimes when we're working with people who are, you know, acutely suicidal, I think it's a pretty universal experience. Like, oh my god, I got to figure this out quickly. I got to produce a suicide. And I sort of, as I was reading about, you know, means restriction counseling, a big piece of his, like, well, if I'm going to join with the client and the client is going to feel that. And the work, like that takes time, right? Like that is not, that's not me talking a lot. That's not me reading off of a form or feeling like that is a, that takes time. So that was one of the other things that I really took away from that was like slow down. Yeah, slow down. A, you know, that anxiety that we feel as clinicians, it's natural. We're afraid and purported. We're afraid because there's death and alluming, right? That is a thing that we're afraid of. And so that fear and that anxiety motivates us to behave in certain ways that lend themselves to, you know, checklist-based approach, coercive interventions, things like that, which, you know, we're recognizing now are not particularly effective. And in some cases may actually be working against our purposes. And so if we kind of go back to the point that I made at the beginning, which is conceptualizing suicide as, from a decision-making framework or choice, I emphasize the clinicians like your patient can kill themselves. And there's not a whole lot you can do about that. And, and you could do everything right. You could provide really good care. You could be really compassionate, really warm, really understanding, and sometimes suicide wins anyway. Because no treatment is perfect. Some treatments are definitely better than others, but even those better treatments are not 100% effective. And so what we need to do is kind of disabuse ourselves of the responsibility of,"I'm responsible for the decision that my patient makes." And recognize that our responsibility as a clinician is to provide effective treatments. And to, and to give our patients those skills, the strategies, those opportunities for them to hopefully then make a different decision than suicide. And, and I think being able to separate that responsibility of what, what really is it fundamentally that I have control over as a clinician that is like, "Well, I have control over the living really good care in being compassionate." And so that, I think, helps to reduce the anxiety for a lot of clinicians because that is something that I think we can do. And we could actually do it really, really well. So this leads really well into your, the next thing I want to talk about, which was collaborative risk assessment. So everybody's familiar with risk assessment. What do we mean when we're talking about when we say collaborative risk assessment? Yeah. So I would say this kind of harkens back to the kind of the idea or the theme of, you know, these sort of checklist based approaches. And again, this is very common now, I think, in many clinical settings, healthcare agencies, of having these forms that we fill out that, you know, delineate certain risk factors for suicide. And then we're supposed to fill it out. And then we just try to fibrous and all that kind of stuff. And I think that can lend itself to a very impersonal clinical encounter because here the task is I have to fill out my form in order to meet compliance requirements. And so I'm going to often ask the questions to get the information that I need to follow the rules. So to not get in trouble is often another way of framing it. And so that I think directly contradicts the importance of building these collaborative relationships with patients. And so a big approach on the collaborative assessment approach is to an essence. And you know, you put the forms aside, but the documentation stuff there will fill out our paperwork later. And just sip with the patients and ask them, what's going on? Like how did you arrive at suicide? And what are the things that contribute to it? And what we find is that through this collaborative or narrative approach, we actually tend to get all the information we've got to fill in on our form anyway. But now there's a coherence to it. And this is the interesting feedback we hear from clinicians when we train them in these collaborative approaches. They say, yeah, up until now I've been collecting information. And so I have my yeses and nose and I check the boxes and I write things down, but the patient says, but there isn't like a coherence integration of the ideas. And that lives itself to this question that I'm asked all the time. It's sort of a frequently asked question, Susanne Krivitri. What are the most important variables? What should I wait most heavily in my risk assessment? And so what we have to do then is accept that collect the information, but do it in a way that we can start to see how this particular decision emerged in this particular context of that particular time for this particular individual. Because then that makes it actually really easy for us to start thinking about, oh, I know what we need to do to make a change in this person's life and how to guide them perhaps to a new trajectory. And so the good news is that when we take better approach, of course, patients really like it. They rate us as more empathetic. They're more likely to engage in treatment. They utilize the strategies. They do their homework assignments. You know, they take their meds, all those types of things because they feel heard and they feel listen to you. And it also through this approach helps them to actually make sense out of their own experience. That's why, why do I feel this way and why am I doing the things that I'm doing? The collaborative approach allows them to piece it together and they say, oh, now it makes sense to me. And it also makes sense to me why you are recommending that I do certain things in certain ways. So why even do risk assessment? Not what not why collect narrative story of a person's experience. That's not what I'm asking. I think that that is clear. The why do risk assessment? I think so. So I do a lot of legal consulting in the United States, you know, from out practice cases and you're getting into these uniquely US cultural thing of like, assuming each other. And I think one of the consequences of the outcomes of that sort of legal kind of cultural context is this notion of stratifying or risk of you need to collect all this information and you need to piece it together and then kind of have a sense that you sort of like there's an implication you should have known that this was going to happen. And I think that leads to this notion of risk assessment. And so it's very, very common, not only in the United States, this happens everywhere, but to kind of think of this as like is this person low risk medium risk high risk something like that. I think we often utilize that risk assessment frame work couched from the lens of this almost like this prediction game of what is the probability my assessment of the probability that this person is going to engage in a particular behavior. And that's where it's like low probability moderate high probability someone ever in it probability something like that. I've since found it helpful to kind of like OK, we can't predict future suicide in particular cannot be predicted. And so risk assessment then I think could be more usefully reconceptualized as more of looking needs assessment. And so when I'm working with the patients and collecting the information from them and documenting in my notes, you know, with low medium high risk things like that. And my head what I found it useful to to do is think of that is what are the yeah what's the level of service needs for this individual. And so in particular someone who's high risk what that signals to me is this person needs suicide from his treatment. They need DBT or BCBT they need crisis response planning things that go directly at suicide risk. Whereas someone who is low risk for suicide. Perhaps you know something like maybe let's just treat their diagnosis because right now the suicide risk is not at the forefront of the clinical picture for this individual. So maybe we we can be thinking of other psychotherapeutic medication based modalities that hit on their problems in life or yeah they're mental illness things like that. And so along those same lines I've you know work with clinicians to reframe this question that's often asked of when do I hospitalized and I'm like well I don't know. I just is there's a really clear answer for that but I can what I have found helpful to think about is in my risk assessments thinking of what does the patient need. And if in my assessment the patient needs sort of like 24/7 care they need medication stabilization they need something about their mental status to be stabilized maybe psychosis, mania, acute intoxication, something like that. So they need medical monitoring and that's where I'm starting to think of something like inpatient care. Whereas they might be high risk because they're really suicidal. But in my assessment they need help managing distress solving problems and perhaps those issues are not going to be adequately addressed in psychiatric inpatient setting. And so that's where I might be thinking of intensive outpatient or just regular help patient. And so the risk assessment framework then like I said I found it useful to think of it as more of a treatment and services needs type of assessment. So everything you said there makes so much sense to me that we are going to it makes sense to have some sort of systematic or quasi systematic way of assessing where this patient is at what they need and then using that to inform treatment. And I mean even sort of hope even if it's not using some sort of a structured form I mean that's kind of what any decent therapist would do right with anything like it doesn't matter what it is that you know it's not just oh you have major depressive disorder so this is what we're going to do exactly right there's nuance there's you collect that. So that that makes a ton of sense to me I guess it's more of the maybe I'm just too literal but I feel like as a field if we like when we call it risk assessment for folks who don't have a lot of you know they get trained in the graduate trading programs then sort of go into practice so they don't have a you know they can't spend you know hundreds of hours doing research and reading and that sort of thing that by calling it risk assessment that it implies that we're doing this to a certain extent. So I'm doing this to assess risk and why would you and we're not an insurance agency so why would you assess risk in less it's to attempt to I guess it's still told true for insurance agency right attempt to predict and then to be able to do something with that prediction like to me by calling it risk assessment it like what else what I assess risk if it wasn't to assess risk for the aim of prediction and then doing something with that prediction. Yeah and it's I think one of the one of the consequences of thinking about risk assessment in that way is that we we often again everyone's trying to find like the algorithm well what are the right pieces that go together which then say oh I should hospitalize this person now or I should do something else and when I consult with clinicians around this is they'll say well they they said that they had a suicide plan or something like that. And so I think I should hospitalize them and then you know my question and responses and what will hospitalization do for this patient that's great. Well, they're high risk as I like okay so what is hospitalization going to do for them like well I mean it'll reduce the risk as I well why will it reduce the risk and usually what most people as well after a few days. The episode will resolve right is like okay so time will pass and that will resolve the risk so can time pass without hospitalization and what are the things that are actually needed to perhaps move this person out of this heightened vulnerability state and once clinicians are thinking of it that way say well they need perhaps they're not hoping with their emotions very well they need like self regulation skills they they have these they're really hopeless and they. They need some help to kind of teach them how to view the world in a different way it's like okay so can you do that without hospitalization and of course the answer is yes and so it's like so just because someone's got a certain score of a certain number on a tool or a screening method or they have a certain experience that we've classified as high risk doesn't necessarily mean that they need hospitalization because if someone is a planned to care for them. Someone is a plan to kill themselves that plan isn't like going to vaporize while they're in the hospital and that plan will probably be still be in place once they're discharged and then they're going to come back to you and so what do you want to be different when that patient comes back to you and if that intensity of treatment is not sort of directly hitting mechanisms or processes that will fundamentally shift where that patient is. And that's where I'm saying well then what's the purpose of hospitalization and so but that and again that's separate from saying that they're in a really really vulnerable state and so we can start thinking now of things like what do we do like phone contact with our patients in between outpatient is increasing the frequency of outpatient therapy sessions maybe that's indicated have we done lethal means counsel with them because if they if they do not have it can be in access to highly lethal methods. So if you're a highly lethal methods for suicide then you know perhaps the safety assessments of this individual can be adjusted accordingly whereas if they have a bunch of really dangerous meds or they have guns in their house and yeah maybe I am going to think about this in a very different way and perhaps hospitalization functions now in a different manner and I'm initially thinking of simply because again I've decided that they're high risk. I'm curious if this is your answer my reading of literature is that when they look when we look overall that hospitalization there's not good evidence that hospitalization prevents suicide that people obviously die by suicide while they're hospitalized and then there's sort of a spike immediately after people discharge is that you're understanding of it too. Yeah that is true I mean there's there's actually never been a study published showing that in patients psychiatric treatment reduces suicide risk. Wow. There's in as you alluded to there's a lot of evidence showing that in the time immediately following this charge is actually a period of heightened risk. Now we don't know if that's because like is the hospitalization increasing the risk for some people I think for some it probably is for some but I think the other possibility is that you know people are admitted they you know time passes they're you know the distress will resolve and then they're released they return to life and then in many cases a lot of the drivers in their life that were sort of pushing their suicide risk. They're not actually changed while they were in the hospital and so they re-enter the same context that was kind of causing the suicidality in the first place and so a new episode emerges but there might be now overlaid on top of that perhaps their medical expenses maybe you've had time off of work and there were other consequences associated with it. So yes there is there is this this sort of I think long standing assumption that this is sort of the gold standard in a high level of care but it's actually never been shown to reduce suicide risk. So with your work sort of on the legal side of things and I know that you know you're not a lawyer we're not giving legal advice here but I think you know I think a lot of times clinicians do operate and they're trained this way this is not a critique of clinicians if anything this is a critique of training programs. That they're trained that like we have to hospitalize you know I have to do a formal risk assessment I have to chart it and I have to if they meet a certain you know if in certain conditions I have to hospitalize and I have to do these things or else I am going to be liable for a book right. So one of my my question for you and sort of based on what you're saying I guess my question is if a clinic and again not legal advice but in your experience when a clinician you know has a suicide a client and they clearly document the sort of the experience of the client the needs of the client and that they clearly document that they are working on serving those needs for that particular person. So that's for that particular client like is that the type of what you would what I'm trying to get at is how can we help therapists to feel comfortable to attend to be client focused rather than you know litigation focused on the client and that's what I'm trying to do is to do a lot of things that are not really so much more than just a little bit of a lawyer. So I was given very early in my career by David Rudd who did a lot of malpractice legal work as well and you vice he gave me was don't spend a lot of time worrying about or trying to avoid trying not to get sued because people can sue you for anything. So I'm even have to do anything wrong and just be angry with you and then you sue you for something and so if you invest time in my decisions based on trying to avoid that that's sort of a fool's errand in many respects. So what you should instead focus your time and attention on is providing good care because you can do everything right and someone could sue you anyway. And you can be sued and also you can still be a psychologist or a clinician and so protecting your license doing good work is actually what matters and incidentally if you focus on doing really good work it actually reduces the probability of you being sued even though it can't completely eliminate it and I found I found that really helpful and I try to pass that advice on the clinicians wherever possible. And it's something very towards and like our team because our clinic takes it's a suicide care clinic and so we we take very high risk patients and it's interesting when we when we're working with new referral sources there you just skeptical are you sure you want to refer these patients to these are the patients that yeah they're like nobody else wants these patients there they're scary they're dangerous they attempt suicide a lot they're crying pain they're complex things like that we're like no that that's exactly the same. So that's exactly who we want and so a part of what we've had to do with our team to manage this is to say now we like what's not too defensive medicine let's do good care and so we strive for best practices and so the best defense is always doing things that are evidence based that are in particular sported that are rational that are reasonable because it's for us and I would argue this might be true for the future. It might be true for the field as a whole it's not a matter of if a patient dies by suicide as a matter of when and so when that patient dies and their family members get together and they think about whether or not they want to file a claim against us what we want to throw their family members and the survivors and any lawyers if they consult with to say this was really good care that was provided and tragedy struck none the less. And so all that is to say is that that sort of defensive mindset it's totally natural and it's completely understandable unfortunately I think it often gets in the way of doing the things that in my experience doing malpractice consulting the things that will protect you the most which is good care. And so and to put a little bit more of a so would it be reasonable to say good care and documenting that good care. Yeah absolutely it so I am one of the points I make so I do was actually just did a training yesterday on this topic on like standard care and best practices and one of the points that I make is I think we've taken these two turns standard of care and best practice and we use them interchangeably but they actually are very different things. Standard of care that is a legal concept but we use it in our clinical practice as a way of sort of synonymous with like good practice or good clinical care but that's actually what best practice is best practice and definition is doing things in procedures that have been shown through research to actually get you the intended effect. And so the what that means is that best practice sort of refers to it kind of implies what is effective whereas standard of care basically means what is minimally acceptable within the profession and there's no requirement from a standard of care perspective to utilize the most effective most scientifically supported procedures all this required for standard care is that you're doing things at a typical mental health clinician would do in a typical setting and so it's kind of just what is minimally acceptable within the profession even if it's not particularly effective. And so we get these two things mixed up we're trying to protect ourselves from the litigation based on in essence a concept that really really refers to doing the bare minimum if instead we focus on always doing what we know and has been shown to be most effective by default you are going to not only meet the standard care you're going to vastly exceed it. So have you gotten any I always ask everybody this what pushback have you gotten for your work. I mean it's been it's been mixed. I would say some of the work that I've done is very well received especially the critiques of you know susur prevention sort of proper. The field as a whole in a lot of the assumptions so there are a lot of people and they typically be our people outside of the susur prevention field so their family members friends, patients people who lived experience who have received it very positively and said things like finally someone saying it out loud. And within the susur prevention community has been mixed I would say most people haven't really said anything but I would say that the positive feedback has overall I wouldn't say it isn't there but people disagree. So what sort of comes down to is that you know a lot of what I've been talking about really does challenge norms it challenges our bedrock assumptions and that's uncomfortable and so it makes total sense to me that you know the field as a whole perhaps has been less receptive and open to the ideas. And so that over time at least if someone is raising the issue and right on the cage perhaps it'll motivate the field as a whole to maybe improve because I personally believe that we're stuck right now we just keep doing the same thing over and over again. And we've really insistent on certain ideas and strategies that you know are not really working I mean we can't say that they're not working it was a we can't say that they're making things worse but we really can't say that they're making these better it's sort of this you know lack of evidence is it was an absence of evidence is up the same as evidence of absence but it's been it's been interesting just to say the least because some people are not happy with the like a crud here comes Craig again he's talking about all this stuff. So what's I mean I think I have a general sense but what what what are like what are what is it specifically I mean I can't go through but that's getting sort of a bee and people's bonnet. So I'm going to say there are a couple of a couple of areas or there's some ideas that actually have not been resistive or well so like my you know arguing that suicide is not solely caused by mental illness that I think by and large people are saying yeah that's actually probably right. Yeah and there's still some holdouts who insist is 100% about depression and anxiety but I would say by and large the field that's been an idea that's been well received. I would say the one idea that definitely I have not has much agreement with is it involved like Susan like Asian screening and I've been a critic of universal screening not screening writ large but a very particular approach to suicidal radiation screening and it's basically screening everybody within a population particularly in low acuity setting select schools primary care clinics community. I think I think I read a paper of yours recently where you were talking about how that basically if you do a standard assessment for depression and then suicide radiation screening that depression actually is more predictive of yeah then the the SI screen is that right am I remembering that correctly. Yeah you are it's so that's I think a great example and I feel like is you know the where people disagree with me they I don't think they fully understand how I arrived at this position because six or seven years ago I was all on the whole we should screen people all the time bandwagon. I think you read you know my own papers and so my old book chapters I'd be like we should be screening more often and so what changed well I received a grant to to basically validate the local utility of universal suicidal radiation screening primary care and my motivation I mean the whole rationale behind going after proposing the study and going after these funds was because there's there are like some bodies in the United States is the US preventive services task force who is you just kind of held the line saying there's not enough evidence to recommend for or against universal screening and a lot of people the system prevention field are really upset about that and I I was as well as like that's that's ridiculous we should of course be right so I propose a study and I said well I'll come up with the evidence that there's not enough evidence let's generate the evidence and so I received grant funding to do this spent multiple years you work on the project and then I analyze the data when everything was done and I discovered that I was wrong. And that universal screening actually was not very effective and then of course that led me to look at you know arguably 50 years of research that have come to the same conclusion but I was able to see and understand those results in a very different way so I was able to overcome my confirmation bias and and so when I tried to start publishing those results that was really where pushback came and and the paper that you specifically reference we compared the PhD now in which is a depression checklist screening tool and we compared that to kind of explicit asking directly about suicidal ideation which again advocates within the field has said we've been kind of I think knocking the PhD now is he is not good enough it's depression that's not suicidal ideation we should stop doing depression screening we have to ask about suicidal ideation as well and what we found was that actually the PhD Q9 the depression screening actually identified a lot more of the patients who eventually attempted suicide than the suicidal ideation items and so it was an opposite of what we expected and again kind of looking then at the body of research and in many respects it was like gosh we actually have known this for a long time before whatever reason we just weren't able to see that and so so I'd at any rate that's kind of really interesting and in this process kind of trying to make sense out of the results early on like why why was I wrong in essence I started to figure out well it's and all kind of boils down to like mathematics and statistics and prevalence rates and things like that and looking then again outside of behavioral health what can we learn from other disciplines and there's actually very similar issues in oncology cancer treatment in particular where they there's this long history of cancer screening tools being wrong highly sensitive and having lots of false positives and leading to unnecessary treatments that actually increase potential consequences and harms because of you know the treatments have side effects things like that and so in the cancer field they've learned their lesson which is why we now have recommendations of instead of screening everybody for colon cancer we only screen men above a certain age and instead of doing mammograms for all women of all ages we only start doing it routinely for you know once women get to a certain age or if they have these other risk factors because the costs out way the benefits if we do it everywhere trying to inject those ideas into the dialogue as it relates to suicide screening has been really challenging it's been really difficult I think for the field to acknowledge that there might be consequences associated with this activity that we otherwise really want to believe is life saving when I you probably familiar with the paper that came out that there's a meta analysis that came out but no it was a systematic review that came out not too long not too long ago I'm getting old handful of years ago sort of talking about the potential eye atrogenic effects of hospitalization for suicide and like that paper reading that really was really influenced me a lot when you talked about the cancer example that triggered that because it's like the like hospitalization while there's not good evidence or maybe any evidence that it's helpful for suicidal folks there's some evidence that it's hurtful for them and I don't want to overstate that I'm sure that there are many cases where it's not and whatever right but but the point is this is not an innocuous intervention and I mean even if you just think about we're going to pluck this person out of their life even if it's just for a few days you know even if just for a few days which oftentimes is longer but you that imagine for any of us plucking us out of our lives for three days that has consequences you know and there is so you know to do that it's not just you know it's not just well it might be a false positive but it's not just a positive it's not just a positive positive but that's okay because we're no no we could be taking people who it is a false positive and actually hurting them you know this is not a you know just an innocuous intervention there's there's a cost to it you know say you're you're absolutely right and and when we think of you know so now here now I'll play devil's advocates up play with them so say well it I mean obviously some screens positive for suicide risk I mean we're not going to just hospitalize everyone that would be a terrible idea and so you should do a risk assessment I mean the whole point of screening is to figure out who needs further assessment so that we can give them the right treatment and the hospitalization is going to be rare it's going to be more likely medication therapy so let that so I say okay well basically what we found in our study that depression PhD 9 study that you mentioned was that in essence what was happening was a suicidal ideation screening it was identifying fewer patients and it was in essence sort of shifting the focus away from the pool of people who were actually attempting suicide and now kind of shining the spotlight on it on people who were not going to attempt suicide and so it's like all right if the purpose of screening is to identify the people who need further attention then the suicidal ideation screening is actually working against that purpose the depression screening is better suited for that purpose and and on top of that we'll let's talk about some of these other interventions that are more probable so things like you know antidepressant medications things like that medications have side effects right you know they can for some people not everyone but it's something like around 20 to 25% of people who are in an antidepressant will experience one or more side effects sleep problems sexual dysfunction fatigue energy changes things like that as like so now in essence when you do universal screening in low risk settings like primary care schools things like that you are now exposing 25% of the positive screens to side effects so those are the potential harms associated with it because the population as a whole the risk of suicide is low the potential for benefit is actually shrunk because there aren't as many people who could possibly benefit as a result so now you've tipped the scales away from overall benefit towards possibly overall harm and here harm meaning not necessarily is causing suicide but these other side effects and things like that and so in the it's again it's well understood in other health disciplines other areas but we've not imported those lessons yet into suicide prevention which is frustrating and so I've sort of gotten a little more assertive with the issue where I've even started asking questions like well how many kids are we willing to harm in order to prevent suicide and if we are and we now have multiple public randomized controlled trials of universal prevention programs in schools that are consistently finding increased depression and anxiety amongst kids and the thinking is that we have an otherwise healthy pool of people and our treatments and interventions that are really great for those clinical clinical cases are perhaps not so great in a healthy population and to further reinforce points is the way to understand this is that you know we have really good treatments for cancer things like chemotherapy if you have stage three stage four cancer chemotherapy could possibly save your life but we that doesn't mean we should give everybody came a therapy to prevent them from getting cancer that's a terrible idea and I think there's similar lessons to be learned when it comes to behavioral interventions like a social intervention and psychiatric medications and I think we just have a default setting of there no risks associated with therapy or with skills training things like that but perhaps there are and perhaps we should be willing to consider that so what are some for folks who want to learn more about what we're talking about now or in general what are some resources of yours or others that you tend to point people towards that I can include in the show notes Yeah, I would say you know published a book a few years ago where I talked about a lot of these issues and the name of the book is rethinking suicide and you know I've since been thinking a lot more about it and so the ideas that I present in the book we kind of deep dive much more so than what we obviously had time to do so today and there are a lot of sort of out growth of that work that are more in like the published academic literature and so I can certainly provide some kind of key citations or key studies that I think people might be interested in. Yeah and if I I mean whatever you want I would be happy to take and include if I if I link to your website is there some thinking that probably one of the things that folks who listen will want to be able to get as sort of the crisis response planning stuff is there is there a link to that on your website? Yeah, there's so I maintain a website is suicide prevention therapy dot com and that has information about BCBT for suicide prevention crisis response planning Lee fillings counseling it's the portal that we have you know for trains and people are always asking how do I learn more how can I learn how to do this and there's information on there for you know if you're in an agency and you want to train all the conditions you can contract with us but there's also links to other third parties that have like pre-recorded different talks and different trainings that we've done that people can watch. Oh that's wonderful I will link to that ladies and gentlemen Dr Craig Brian. That's a wrap one hour conversation as I noted at the top of the show be much appreciated you could spread the word to anyone else who you think might enjoy the show. Until next time.
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