Client Suicide and Clinician Response: Ensuring Policy Guidelines and Clinician Safety

In looking at issue of suicide within mental health field, we know that a person who suffers from mental illness, is more likely to be at risk for suicide.  According to the Mental Health America website of suicide victims suffer from major depression or bipolar (manic-depressive) disorder”.  One aspect that doesn’t often get looked into, is how does suicide of a client affect the clinician that they work with?  In working in mental health field, depending on setting and caseload, clinician’s often have fluctuating caseloads, and might lose a client to suicide, and then be required to have short turnaround in picking up a new client to replace them.  In dealing with a population that might show higher risk of suicide, the question becomes, are we ensuring that clinician’s are protected by policies, have confidence in being able to assess suicidal behavior?  An article does a study on 172 therapists, 125 who are from private practice, and 47 from institutions, and tries to assess their responses to suicide from clients.  The study finds that of these therapists, 85% from institutional setting and 17% from private practice had experienced at least one suicide in their professional careers.  From this article, it appeared there was more of a propensity for clinicians from institutional settings to be more at risk for having experienced a client suicide.  This would make sense in that institutional setting, clients would have more severe symptoms of mental illness, and in general, having to be institutionalized is a result of not being able to take care of one’s self, or possibly self harming behavior in the past.

The same study found that for psychiatrists who had “less than 5 years of professional experience” reported significantly more feelings of “guilty, shocked and insufficient” at their job, after 6 months of the study, opposed to colleagues with more experience. This makes argument for importance of developing policies, as well as offering trainings to ensure new staff feel confident in assessing clients for suicidal risk.  One of the main sources of distress, interestingly enough, was that of “fear of reaction of parent’s relatives” and that was found to be even higher than fear of a lawsuit in this study. This study also found that in dealing with client suicides, of the therapist responses, 80% reported being “supported by the institution” they worked for, 72.3% found some type of “conference” around grieving to be helpful, and 44% had reported wishing they had some type of “conference”. This data shows support for clinicians wanting to feel supported or protected by policy guidelines of institution, as well as some type of debriefing process to allow discussion of the client’s case.  Of all the therapists involved in the study, “one third or 34.5% suffered from severe distress”, which the study did not find significant differences in gender, but were slightly more prevalent among women, and also the study pointed out distinction that with mild distress, usually over 6 months, symptoms lessened, but with severe distress, symptoms were persistent over this time.  The study shows a  prevalence of “severe distress” within clinician’s, which argues for being able to notice this within staff, as well as developing policies that ensure staff protection and confidence in being able to assess client’s for suicidal risk.

Another article  was a study done within the United States Air Force and collected information from 74 of medical treatment facilities, to determine if trainings around suicide assessment, could impact clinician confidence, as well as impact policy or clinician ability to assess suicidal behavior.  One argument that the article starts with is the fact that most clinician ability to do suicide assessment effectively, is dependent upon organizational policies, as well as clinician motivation to access literature on, or continuing education into this area.  For instance, Bongar and Harmatz (as cited by Oordt et al. 2009) found that “only 40% of graduate programs in clinical psychology provided any formal training in clinical work with suicide patients”.  In other words, even clinicians with advanced degrees in psychology or other mental health degrees, would have minimal exposure with how to work with suicide patients, which puts their ability to be effective on what they learn working in the field, putting further emphasis on training their employer offers, what program policies are around this, etc. Depending on what state this occurs, continuing education might not be required, and so this  would put more emphasis on the clinician seeking out these trainings.  The article offers a link to the Air Force website, which offers “18 recommendations for effective clinical work with suicidal patients”.  Without continuing education, the article by Oordt et al. (2009) describes that clinical supervision would be primary source of setting guidelines for how to assess suicide risk.  This requires that with good policies, supervisors could also feel confident in providing feedback to clinicians, as well as in clinicians being trained and having knowledge of what to do in these situations, wouldn’t need as much supervision.

Going back to the article, the study used a 12 hour training session, with 4 hours spent on “suicide assessment”, 4 hours on “management and treatment of suicidal behavior” and 4 hours on “military specific practices, policies” around suicidal assessment.  The goal of the study was to follow up on participants from the training and see if this impacted them, up to 6 months after the trainings.  The study was made up primarily of 82 participants, 48% who were doctorate psychology clinicians, 27% doctoral social work majors, and 13% that were psychiatrists.  Initially, of these participants, 43% reported “little or no formal trainings in graduate programs” around suicidal assessment, and 42% reported “little or no postgraduate or continuing education”.  This information supports the findings that even with advanced degrees, clinicians don’t have much exposure to policies or guidelines around how to do suicide assessment?  At the 6 month follow up, 44% of all participants reported “increased confidence in managing suicidal patients”, 83% “changing suicide practices”, and 66%, “changing clinical policy”, as a result of attending the trainings. The article also offers a 9 step guide to what trainings should look like, around suicidal assessment.  This study was done specifically with the Air Force, but offers an example of support for giving clinician’s trainings around practice of suicide assessment, as well as making sure they have knowledge of what policies are and what is expected of them by organization, in doing suicide assessments.

From these articles, we can see prevalence of “distress” amongst clinicians in having to deal with a client who has committed suicide.  Oftentimes, as clinician’s, we feel sense of needing to be detached or be professional in dealing with our clients, and yet it is important to understand it is normal to experience some grief in losing a client to suicide, or other factors.  What is important is knowing organizational policies, or ways in which we are expected to assess suicidal risk, as well as knowing resources available to aid us.  As these articles point out, through trainings and continuing education, we can feel more confident, as well as develop better policies to deal with clients that display suicidal behaviors.  Here are some lists of resources for info on defining policies around suicide assessment, as well as helpful tips for clinician being able to deal with loss of a client to suicide.
Mental Health America (Suicide Info)
SAMHSA (Statistics on Suicide Likelihood)
Suicide.Org Non-Profit Organization (Warning Signs)
Mayo Clinic Website (General Coping Skills for Losing Someone to Suicide)

Citations

Oordt, M.S., D.A. Jobes, V.P. Fonseca, S.M. Schmidt (2009). “Training Mental Health Professionals to Assess and Manage Suicidal Behavior: Can Provider Confidence and Practice Behaviors Be Altered?” Suicide and Life-Threatening Behavior 39(1).

Wurst, F.M., S. Mueller, S. Petitjean, S. Euler, S. Thon, G. Wiesbeck, M. Wolfersdorf (2010).  “Patient Suicide: A Survey of Therapists’ Reactions”. Suicide and Life-Threatening Behavior 40(4).

submitted by Jim Linderman.  Jim is currently a M.A. student with University of Colorado-Denver Sociology Program.

More about evidence based practices

Last week we spoke about Evidence Based Practices (EBP) and how their use has helped create more effective interventions. However, we also mentioned that EBP are difficult to implement. We spoke about how part of the problem is that they can be costly and can go against what most people in the field are used to doing in their practice. This time, I want to explain why most times, these interventions are costly and difficult to move into real-world practice, not only because they may go against what the field is used to do, but also for some other practical reasons.
EBP are usually tested under very rigorous conditions: The most stringent criteria for calling something an Evidence-Based Practice requires the use of a randomized control trial approach. That means that participating individuals may be assigned to one of two (or maybe more) groups: One that receives the treatment or one that receives nothing. Now the justification for doing something like this is because we want to be able to demonstrate that the reason we see change after the treatment, is due to the treatment and not other reason (for example: just the passing of time or in some cases, due to some developmental reasons, when developmental changes make sense). Now, even in those conditions, there may be potential confounding variables that may affect the final outcome.
One of the biggest problems facing many treatments is the fact that many times, individuals show improvement just because they are told (or they believe) that they are receiving some wonder-therapy (or drug). This is so prevalent in clinical trials that people speak about the “placebo effect”.  Therefore, a way to control for the potential effect of placebos is to include a treatment condition which is a placebo (when testing medications, people speak about “sugar pills”) or what may be considered the “normal treatment” (which sometimes is labeled as “business as usual”), where those who did not go into the treatment being tested are receiving the treatment that they might have received had there not been this treatment under testing. Placebo is a very powerful effect, and most of the therapies that sometimes are advertised on TV may work, because of this effect (quiz: how many times have you seen in those late TV ads a comparison group? Or comparisons against a placebo control?).
There are multiple ways to try to prove that a specific intervention is working, but as explained, most people tend to agree that the best approach is to use what is known as the “gold standard” or random assignment to different clinical conditions. The reason random assignment is considered the “gold standard” is that for the most part, it balances out many variables that could potentially affect the outcomes in unexpected ways. Things like age, gender, ethnicity, length of time with the illness, type of treatments received in the past and so forth. How will random assignment control for all of that? Because every individual with any potential combination of these variables  has the chance of being assigned to one of the treatments in the study. Therefore, it is expected that individuals with many if not all the potential combinations that may affect the final outcomes end up in one of the groups in the study, and therefore the effect of all those variables cancels out.
All this dancing is so scientists and the public in general can make informed decisions about the effectiveness of a treatment (i.e., are my outcomes better when I use treatment “A” as opposed to treatment “B”), as well as being able to generalize to a larger group of people than those included in the study. After all, if you were not included in the study, what good will it do to you to know that a program may work if you are not sure that the treatment will work in people like you?
Doing this work means time and money. People involved in testing the treatment needs to conduct multiple studies so they can get some assurance that the results are sound and can withstand multiple tests, under different conditions. They also need to be closely monitored so researchers can be alert if something is not going well. If the new treatment under scrutiny has the potential for being harmful, then they may want to stop the study before too long. On the other hand, if the results are going very well, perhaps it is time to stop the study with confidence that the new treatment will work as expected (though when treating human lives, you don’t want to take any chances).
 There are multiple institutions that have created databases where evidence for or against Evidence Based Practices can be found. The Substance Abuse and Mental Health Services Administration (SAMHSA)  maintains a website with links to several organizations where such information can be found.
Creating and documenting the effectiveness of a specific intervention is not enough. In a country as diverse as the U.S., there are many instances where an intervention that has been proven to work for a specific group of people (say African American), may not necessarily work for another ethnic group (e.g., Latino). The reasons can be associated with genetic makeup as well as with ethnic background (customs and traditions, for example, can be a big impulse or deterrent for some interventions). Therefore sometimes interventions that have been proven to work in an ethnic group (or in a research setting) need to be tested under different conditions (e.g., a different ethnic group or on a community-based environment). This is no easy task, which once more affects how quickly an intervention can be used outside the testing grounds.
This is a very active area of research which is known as validity. People speak about internal or external validity, and if you ever took a “research methods” class in college, then you may recognize many of these ideas or even terms. One book that describes the rationale an many specific examples is  Shadish, Cook and Campbell. However, be warned that this book can be hard to read without some introduction to research methods
One final note: Evidence Based Practices are the top of the pyramid, but there are some interventions/programs that have not been able to prove their worth using the most restrictive criteria (the gold standard) and yet are considered worth more research.
A ‘Promising model/practice’ is defined as “one with at least preliminary evidence of effectiveness in small-scale interventions or for which there is potential for generating data that will be useful for making decisions about taking the intervention to scale and generalizing the results to diverse populations and settings.” Department of Health and Human Services Administration for Children and Families Program Announcement. Federal Register, Vol. 68, No. 131, (July 2003), p. 40974. These are interventions where some initial testing has been done, and the outcomes observed so far seem to indicate that the intervention may be effective. However, more and more strict testing is needed to endorse it as an EBP.
Emerging practices, on the other hand, are “practices that have very specific approaches to problems or ways of working with particular people that receive high marks from consumers and/or clinicians but which are too new or used by too few practitioners to have received general, much less scientific attention.”  We took this definition from the Oakland County Community mental health authority. In this case, it is argued just like in the case of the promising practices, that the intervention being described has produced effective outcomes, but much more testing is still necessary.

Evidence based practices

Currently, one of the most important areas in healthcare is accountability.  As part of this movement toward accountability, the mental healthcare industry and their stakeholders tend to talk about Evidence Based Practices (EBP) as a way to link programs to desirable outcomes.
Evidence based practices can be found in multiple areas: from Education to Mental Health. And within mental health you can find them from medication (Kentucky Medication Algorithm; and Texas Medication Algorithm  where the main goal is to use the medication that will create the best outcomes), to specific interventions or programs like Assertive Community Treatment (ACT) in adult individuals and Multi-systemic Therapy (MST)  for youngsters; to specific illnesses like Schizophrenia  and Bipolar disorder.  Furthermore, the Substance Agency (SAMHSA) which supports most substance abuse and mental health funding at the Federal level, maintains and supports through funding multiple studies to determine and encourage the use of EBP throughout the country (go here to see what SAMHSA endorses) Professional organizations like the American Psychological Association, the American Psychiatric Association, as well as organizations for Occupational Therapy, Psychiatric Rehabilitation, Nursing , etcetera, endorse the use of EBP with their members. Insurance providers, Federal funded entities like the National Institute of Health and Consumer advocacy groups like NAMI  fund or endorse Evidence Based Practices.  In fact, Tanenbaum 2008 states that “EBP is a matter of mental health policy in USA” (page 699).
So what is the big deal about EBP? Why would we want to use EBP rather than other practices that are not considered EBP’s? The main reason has to do with the definition of EBP, and the rationale for the creation of EBP. There are multiple definitions for Evidence Based Practices (this is one); but most of them speak about interventions that are backed by empirical or scientific research. What that means for the individual on the receiving end is the certainty that what is being used is scientifically sound, and not just some unproven therapy, or, even worse, some form of quackery that will not deliver the expected outcomes on a regular basis.
If EBPs are the best thing since sliced bread, then why is there resistance to implement them? There are several issues associated with the implementation of EBP. One is related to the level of information regarding EBPs (who knows about them and how much). Evidence about consumers knowing or participating in decisions regarding services (in this case, EBP services) is usually limited. Tanenbaum, for example, found out that though consumers may be willing to use EBP, they are rarely consulted about the services they received (the decision is not up to them).
Another area is the science to service gap associated with research. There are multiple numbers being tossed around, but Druss 2005 speaks about a twenty year gap between scientific research and implementation in an applied setting. In that regard entities like SAMHSA are doing the best to help move research to practice. For example, SAMHSA instituted an award for centers that do their best to bridge that gap (MHCD received this award in 2009  for its Growth and Recovery Opportunities for Women (GROW) program).
Finally, there is also resistance from providers to implement EBP for multiple reasons: From need for new training, to expense, to the importance of fidelity to the model. 
• Regarding training, most EBP require that clinical people learn new techniques, or ways to do things that seem to be counterintuitive to what is known or has been practiced for many years. As an example, of new implementations for trauma-oriented for women survivors of trauma, the Trauma Recovery and Empowerment Model TREM;  uses an approach where abuse is not seen as “the primary problem”.
• Regarding expense, many of these interventions require very extensive training, or require special certifications to be used. This not only means expense in terms of training and materials, but also certifications; not many centers can afford such implementations.
• Finally, most of these models have been created in research settings, under very controlled situations, and they have been proven to work –mostly-- under those circumstances. Therefore, the model creators will require that you “follow the model” with fidelity. For example, clinicians may have to be on call on a 24 hours/7 days a week schedule; or the ratio of clinician to individuals receiving services is 1-10. And if you do not follow the model within some specific bounds (determined by instruments created by the model designers), then the center or clinicians doing the implementation are formally not using the model, or will not be endorsed by the model developer.
Why then try to use Evidence based practices? The short answer is because they have been proven to work in most situations. That is, the expected outcomes are met as described by the model. For example, youth receiving Multi-Systemic Therapy (MST) will stay at home (rather than at out-of-home-placements), stay in school, reduce the number of arrests, and reduce psychiatric symptoms and substance/alcohol use. Therefore, most people figure that the cost, extra training, continuing certification is worth the hassle. But the field is new, and sometimes it is not clear whether all the program components work as intended, or whether the model really works as intended outside the –most times-- very restrictive conditions imposed by the program developers. This is a new field, and new evidence is mounting every day that speaks in favor or against what we know about EBP.  We’ll have more to say about this area in future blogs.

Mindfulness and Psychotherapy

The practice of mindfulness is a practice that is finding increased attention in the application of psychotherapy. What exactly is mindfulness as it relates to psychotherapy? The term mindfulness comes from the word sati, taken from the Buddhist tradition of meditation and psychology. This word suggests awareness, attention and remembering. According to Dr. Ronald Siegel, Psy.D, Assistant Clinical Professor of Psychology at the Harvard Medical School, mindfulness as it relates to psychotherapy is assisting a person to learn to cultivate a practice of awareness of a present emotional experience. In the book co-edited by Dr. Siegel (2005), Mindfulness and Psychotherapy, New York: Guilford Press, Dr. Siegel suggests that it is also very important that the person is able to practice acceptance of that emotional state as it arises. As used in psychotherapy, mindfulness is a practice that systematically teaches the patient how to accept their emotional experience. This is similar to the use of mindfulness in Marsha Linehan’s Zen-inspired dialectical behavior therapy (DBT). Linehan, M. (1993). Cognitive-behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. As emphasized in DBT, emotions can become overwhelming, and this may impact one’s behaviors and thoughts in a negative or destructive manner. Mindfulness as utilized in dialectical behavioral therapy attempts to break this pattern by helping the patient better manage these emotions.
  While mindfulness has most often been related to Buddhist or religious/contemplative practices, mindfulness is now also being integrated into what we might call the more traditional forms of psychotherapy as what is now being called the third wave in behavior therapy. The first wave was Operant and Classical Conditioning and the second one is Cognitive Behavioral Therapy. The third wave now incorporates mindfulness into the well know evidence based practice of Cognitive Behavioral Therapy as Mindfulness-Based Cognitive Therapy, (MBCT).
 Mindfulness-based cognitive therapy was developed by Zindel Segal, Mark Williams and John Teasdale (2001), Mindfulness-Based Cognitive Therapy for Depression: a New Approach to Preventing Relapse, New York: Guilford Press. Their work was largely influenced by the work of Jon Kabat-Zin whose work was discussed in a previous article found on this blog site regarding the work of Kabat-Zin and the development of the Mindfulness-Based Stress Reduction Program at the University of Massachusetts Stress Reduction Center.
Mindfulness-based cognitive therapy is a blend of cognitive behavioral therapy (CBT) which focuses on changing our thoughts in order to change our behaviors, and the meditative practice of mindfulness, a process of identifying our thoughts on a moment-to-moment basis while trying not to pass judgment on them and experience them with acceptance as suggested by Dr. Ronald Siegel. While cognitive behavioral therapy has always emphasized the end result of change of one’s thoughts, mindfulness really looks at how a person thinks — the process of thinking — to help one be more effective in changing negative thoughts. What does some current research suggest about the effectiveness of this newer form of psychotherapy?
Coelho et. al. looked at research about mindfulness-based cognitive therapy and found four relevant studies that examined the effectiveness of this approach. Coelho, H.F. (2007). Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. J Consult Clin Psychol., 75(6):1000-5.
The current evidence from the randomized trials suggests that, for patients with 3 or more previous depressive episodes, MBCT has an additive benefit to usual care. It is important to note here that MBCT is designed to help people who suffer from repeated bouts of depression. Coelho found however, because of the nature of the control groups, these findings cannot be attributed to MBCT-specific effects. The researchers did suggest that MBCT has found some positive results for those with a more chronic depression but they could not say that this was as a result of specifically MBCT alone.
It is clear that there is an ever increasing mindfulness oriented model of psychotherapy. Treatment strategies can be derived from the basic elements of mindfulness – awareness of present experience, with acceptance. A review of the empirical literature by Baer (2003); Baer,R. , Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10(2), 125-142, suggests that mindfulness based treatments are “probably efficacious” and en route to becoming “well established”.
The possible emerging model of mindfulness as integrated into psychotherapy can be seen to have promise in many areas of psychology and psychotherapy and has indeed become well established. Similarly empirical research in this area has seen a significant increase. In 2003 at the time of the review by Baer, there were several hundred empirical research articles on mindfulness and psychotherapy and now, 2010, one can find several thousand. Mindfulness is beginning to move into other areas such as brain science, health/medical psychology and positive psychology. It seems that the clinical literature is promising and psychologists and mental health clinicians have the opportunity to integrate a form of mental practice that is based on a 2,000 year old contemplative practice of bringing the mind to the present state, experiencing this state and accepting this state. Additional Resources
University of Massachusetts Medical School, Center for Mindfulness and Medicine
www.NICABM.com
Dr. Ronald Siegel, (2010), The Mindfulness Solution: Everyday Practices for Everyday Problems, New York: Guilford Press
By Marcia Middel, Ph.D.
Dr. Middel is the chief psychologist at the Mental Health Center of Denver. She is also the Director of the Center for Integrated Psychological Services (CIPS) and team associate with MHCD Evaluation and Research team
 

Our Role in Preventing Suicide…

With the recent untimely death of Broncos WR Kenny McKinley and tragic loss of several college youth across the nation this question has been thrust into our community’s collective conscious. Sadly, suicide has become an all too common occurrence within our society, while at the same time remaining a rather taboo subject for our own interpersonal relationships. Despite our frequent reluctance to discuss this issue with those that we care about, there are vey few of us who have not had our lives directly touched by suicide, whether through a child, parent, sibling, relative, neighbor, coworker, or acquaintance. We’re often left with lingering existential questions that challenge our own sense of meaning in life... Why? How could someone with seemingly so much going for them take their own life? What could lead a person to believe that suicide was an option in their situation? What could I have done differently or how could I have known this was going to happen? Perhaps the most important question we can ask ourselves, as we seek to move forward and create meaning from such a seemingly senseless act, is what can we do to reach out to those still suffering in silence to help prevent suicide from taking another life? Through this brief post I hope to review current research to provide some context to the national suicide epidemic, dispel some myths about suicide, and empower you with some tools and resources to make a positive impact on the struggle against suicide.Colorado consistently has one of the highest suicide rates in the nation, with suicide representing the 7^th leading cause of death across all age groups and the 2^nd leading cause of death for young people ages 10-34. Just last year Colorado had its most deaths by suicide on record at 940. Nationally, death by suicide claimed the lives of 34,598 people in 2007. It is estimated that another 11 suicide attempts occur for every 1 death by suicide. These are staggering and heartbreaking statistics that highlight the all too prevalent nature of suicide within our nation and immediate community. For more information on some of the national suicide statistics you can visit the National Institute of Mental Health (NIMH) or see the Suicide in Colorado report for information specific to this State.

             Given the widespread nature of suicide within our communities, one might think that this issue would be a more frequent topic of conversation and routine preventative effort by nearly all people. Unfortunately, some of the myths and stigma surrounding suicide has prevented this from becoming the case and we all too rarely openly discuss or ask about suicide until the topic has been thrust before us by the loss of someone we love or a prominent public figure. By then it’s already too late. Our own fears, assumptions, and false beliefs about suicide often get in the way of reaching out to those in need around us.

• How can I possibly say anything that might be helpful to someone considering suicide? People contemplating suicide are just like you and me. We have all been through some difficulty in our own lives and share a common humanity which gives us the capacity to help someone who is depressed or thinking of taking their own life.
• If I say anything it might make the person upset or give them an idea that makes them more likely to hurt themselves. This is actually the opposite of what research has found to be true. Being direct with someone about suicide generally lowers their anxiety and sense of isolation that has been created by the stigma surrounding suicide. By opening a line of communication we can cue in to any warning signs and decrease the risk of an impulsive act. Additionally, if you’re worried that someone you know might be considering suicide, it’s nearly a guarantee that they’ve already at least thought about this themselves.
• People who consider suicide keep their plans to themselves. This is another common misperception that has been debunked by the literature. Psychological autopsies on those who have completed suicide found that approximately 95% of these individuals had in some way communicated their suicidal intent.
• People who talk or joke about suicide don’t actually do it. As previously highlighted, nearly all people who attempt suicide convey their intentions in some way. Increased talking about death or suicide is a frequently evident precursor in individuals who try to take their own life.
• Once people make up their mind to complete suicide there’s no way to stop them. Most people have conflicting feelings about suicide and are generally ambivalent about their decision to complete the act. Interviews with Golden Gate Bridge survivors indicated that one of the most common thoughts that entered their minds after jumping from the bridge was “I wish I hadn’t done it.” This is also why the vast majority of people convey their intentions in some form or another before performing a suicidal act. People generally want help but don’t know how to ask. Suicide is the most preventable cause of death and any positive action you take may save a life.

            I know how incredibly difficult it can be to break the circle of silence surrounding suicide. I live with my own painful reminder of how I was unable to do just that with an acquaintance during my sophomore year of college. However, as I’ve learned to break that silence and reach out to those in both my personal and professional lives (as both a crisis helpline worker and therapist) I’ve come to appreciate the incredible power of a simple question or gesture of support to someone contemplating suicide. Whether a person is actually considering suicide or not, the mere act of asking a question offers a tremendous opportunity to create a profoundly meaningful connection with another person that you may find not only has a significant impact on that person’s life but on yours as well.

            So what can we do to help? Everyone can play an important role in suicide prevention by being mindful of several simple things and being willing to reach out to others whenever warning signs arise. Moreover, we can all work together to help break the silence and lower the social stigma surrounding suicide.

• Be attuned to any suicide cues or warning signs in those around you. Listen for direct verbal cues (e.g. I wish I were dead, I’m going to kill myself, I’m going to end it all) and indirect verbal cues (e.g. I’m tired of life, You won’t have to worry about me much longer, You’d be better off without me anyway, I just want out of it all).
• Be on the lookout for behavioral cues (e.g. previous suicide attempts, giving away possessions, sudden disengagement, making arrangements for an absence, acquiring a weapon, storing large quantities of pills). Symptoms of depression and drug/alcohol abuse are present in approximately 90% of instances of suicide.
• Also, be mindful of times in which previously depressed individuals seem to be getting better or have an increased level of energy as they may now feel as though they have the resources to carry out the act they have been thinking about for so long. Moreover, as counterintuitive as it may sound, the hours preceding an attempt may involve an air of happiness or calm as the person has resigned themselves to death.
• Check-in with people following any major life changes that may represent a situational cue for suicide (e.g. loss of job, end of a significant relationship, death of a family member or friend, difficulties at school, serious medical condition).

            Whenever you have any concerns the most important thing you can do is simply ask if someone is considering suicide, or if you’re unable to then find someone who can. Ask the question and then listen. Listen without judging and then ask if you can help them get connected with resources to help. For additional information on suicide and how you can help people struggling with this issue checkout the National Suicide Prevention Lifeline and the Suicide Prevention Resource Center.

By Scott Nebel, Psy.D.

• Scott is a Psychologist on MHCD’s Intensive In-Home Treatment Team and collaborates with the MHCD Research Institute.

Books on Suicide and Depression:

Suicide: The Forever Decision by Paul Quinett

Darkness Visible by William Styron

Night Falls Fast by Kay Redfield Jamison

Mindfulness and Mental Health

Psychotherapy and spirituality have mingled with one another since the early development of talk therapy. Early psychotherapists relied on their philosophical and spiritual beliefs as they worked towards an understanding of the soul, the spirit and the self. With the development of more concrete therapeutic techniques, the use of religion and spirituality in psychotherapy has fallen out of favor (especially with the growing interest in evidence-based practice). One exception to this is the major influence that meditation has had on modern day psychotherapy. Meditation has been a part of many different religious traditions (e.g., Hinduism, Taoism); however, I believe that most of us associate it with Buddhism. As a beginning point for my research, I conducted an online search using only the term “Mindfulness”. The results pointed to Jon Kabat-Zinn, a physician who has dedicated his career to highlighting the benefits of the use of meditation in health care. The results also helped to clarify the definition of the term “mindfulness” as a reference to the therapeutic application of meditation. This helps in understanding the interchangeable relationship between the terms meditation and mindfulness.

Understanding the use and benefits of mindfulness required more in-depth research, much of which lead to resources rather than answers. For example, Dr. Daniel Seigel has written several books on the process of incorporating mindfulness based practice with psychotherapy: Mindsight and The Mindful Brain.

Jon Kabat-Zinn, mentioned earlier, has written extensively on the use of mindfulness in reducing stress and anxiety. His books include: Full Catastrophe Living, The mindful Waythrough Depression, and Wherever You Go, There You Are.

Common to both these authors is their emphasis on the relationship between mind and body. Many who practice mindfulness in psychotherapy believe that awareness of the self in the present moment (including past repressed emotions and memories) is the pathway towards successful living. Through mindfulness, a clinician can help a client move away from the avoidance strategies implemented in the past. The goal, in this type of therapy, is to help a client gain awareness of the self by understanding and processing feelings throughout the body – notably while processing painful affect and memories. In essence, mindfulness is the opposite of mindlessness. This idea is rooted in the belief that negative emotions need to be processed before an individual can move towards successful living.

Now to the ultimate question, “Does Mindfulness Work?” For this question I moved away from “Google” research and utilized other resources (e.g., PsychInfo and PsychArticles databases). The results led to many articles with only a few catching my attention. For instance, an article titled “The Effect of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-Analytic Review” reviewed 39 studies with participants receiving mindfulness-based therapy for a range of conditions (i.e., cancer, generalized anxiety disorder, depression, and other psychiatric or medical conditions). The researchers found that mindfulness-based therapy was moderately effective for improving anxiety and mood symptoms, concluding that mindfulness-based therapy is a promising intervention for treating anxiety and mood problems in clinical populations. It is important to note that this study is a summary of 39 other studies on the topic of mindfulness. This is a convenient way of capturing a wide-range snapshot of the available research.

A study titled “Mindfulness-Based Stress Reduction and Health Benefits: A Meta-Analysis” concluded that Mindfulness-Based Stress Reduction (MBSR, “…a structured group program the employs mindfulness meditation to alleviate suffering associated with physical, psychosomatic and psychiatric disorders…”) may help a broad range of individuals to cope with their clinical and nonclinical problems. Finally, a study titled “The Effects of Mindfulness-Based Stress Reduction Therapy on Mental Health of Adults with a Chronic Medical Disease: A Meta-Analysis” concluded that the same intervention (MBSR) has small effects on depression, anxiety and psychological distress in people with chronic somatic diseases. They add that integrating MBSR in behavior therapy may enhance the efficacy of mindfulness based interventions. Here below is a link to the first MBSR article and an abstract of the second MBSR article: 

So, back to the question “Does mindfulness work?” In my opinion, the answer is that it does work, however (like all other interventions/techniques), not across all populations, conditions or contexts. Current research is primarily focused on understanding which populations, conditions and contexts would benefit most from mindfulness. The first meta-analysis covered above showed that the use of mindfulness is moderately effective while the following two studies resulted in less positive findings (e.g., “may help…” and “…has small effects…”). I think this speaks to the need for a more detailed understanding of mindfulness as a technique in psychotherapy. For instance, it may be the case that mindfulness successfully compliments certain traditional forms of psychotherapy while conflicting negatively with others. It may also be the case that mindfulness fits well when it comes to certain psychological/psychiatric conditions but not others. For now, it does seem that mindfulness based psychotherapy is a useful practice for addressing general anxiety and depression. 

By Ous Badwan

Ous is a Psy.D. Student from the University of Denver’s Counseling Psychology program  currently doing a research internship at MHCD.

More about neuroplasticity

Last week we described briefly some research about the relationship between bran plasticity and emotional wellbeing. This week, we would like to talk about another area where there is some very exciting research that links brain plasticity and mental wellbeing. In addition to the symptoms usually associated with schizophrenia (hallucinations, delusions, disordered thinking; see NIMH’s website for a description of schizophrenia and its symptoms, there are other symptoms which are as important but hardly mentioned and include: inability to understand information, trouble focusing attention, and problems with memory (in particular, maintaining and using information which is known in behavioral research as “working memory”). The reason why this is an important deficit, is because there is evidence that shows that cognitive deficits like those described, will have an impact on more functional outcomes; things like employment, education, social interaction, and even ability to live independently.

There is some very recent research that focuses on some of the brain mechanisms that may be involved in this deficit (some neurochemicals and their receptors that do not work as intended). Also, there is some research that tries to tackle these deficits from a different point of view: Cognitive Remediation Therapy (CRT), whose main goal is to teach individuals some strategies to improve their cognitive skills go here and here  for links to some of these studies). These skills include things like rote memorization, and/or the use of strategies to memorize/pay attention to key pieces of information.  Regarding CRT, one study that we found is a meta-analysis by McGurk and others. Meta-analysis is a great tool for research, because it helps summarize in a scientific way the information contained in many studies. In this case, the authors summarized and compared the results of 26 studies to explore whether the use of CRT helped individuals with schizophrenia not only to have better memory, attention and problem solving, but also better functional outcomes. The analysis showed great promise in several areas: improvement in cognitive areas like attention, verbal learning and memory, ability to process information faster and ability to solve problems. Interestingly, the analysis also showed that at least within these studies, there seems to be no relationship between the length of the program (number of hours spent learning the techniques and practicing) and the improvements observed. It seems that as long as the individuals practiced between 5 and 15 hours (the program with the maximum length was 15 hours), there were no differences in improvement, with one exception: Verbal learning and memory. However, it is possible that this relationship does not seem to be important, because the studies did not go far enough in time to observe changes. Only six programs assessed changes in the individuals 8 months after the program ended. Therefore there will be no way to know if the effect of number of hours helped change or maintain the improvements after 8 months.

There were two other interesting findings. One is that the CRT programs seem to have minor impact on the more traditional symptoms of schizophrenia (though there are some other studies that suggest improvements in mood and self-esteem).  The other finding is also a minor improvement on the functional outcomes; things like working on competitive jobs, improvement in the individual’s social relationships and ability to solve interpersonal problems. However, for the second finding, the researchers also found that studies that combined CRT with psychiatric rehabilitation had a stronger effect than those studies that used only CRT.

Although the results are not conclusive, this time, the bottom line seems to be that the combination of clinical therapy, psychiatric rehabilitation and some type of cognitive improvement program holds the most promise as far as being able to improve memory, attention, concentration, and also improve functional outcomes like maintain employment, and have meaningful relationships with other individuals (go here for similar conclusions).

Is it possible that the results found are just like a “sugar pill” (i.e., a placebo effect)? It does not seem likely. Some of the studies compared CRT versus more clinician’s attention and found that individuals who attended CRT showed much more improvement than those who received only more clinician’s attention.

Some factors still need further study. For example, since only a few studies reassessed individuals a few months (8 at most) after the program ended, it is unclear if the number of hours of practice will have a significant impact on maintaining this cognitive improvement longer. Similarly, only a few studies try to relate changes in the more cognitive tasks (memory, attention, problem solving) with functional outcomes (going back to –and maintaining—employment, improvement in social relationships). This is an area where the Mental Health Center of Denver (MHCD) and the MHCD Research institute are currently working to further understand the relationship. Stay tuned for forthcoming blogs where we will talk about mental health research using functional outcomes.

Research on brain plasticity

There has been some recent research that seems to point toward the fact that the brain is much more pliable than what we used to think. This is part of a field known as Neuroplasticity. Just to check, I decided to run a quick search on Google of the word “neuroplasticity”. According to Google, I got “about 838,000 results”, and it only took “0.20 seconds”. This can be a little overwhelming, if you want to learn about what neuroplasticity can do for you. There are a few blogs where the term neuroplasticity can be found, but someone who has written a lot is  beyond meds . Many of the posts related to neuroplasticity can be traced back to a book written by Norman Doidge: The brain that changes itself. In his book , Dr. Doidge had stories about different individuals who have been able to overcome challenges by “rewiring their brain”. Some of the individuals and stories were related to some major issues, like having a stroke and having to relearn how to walk or talk. But there were a couple of chapters dedicated to emotional imbalances. One that tries to explain sexual disturbances and one related to mental illness. If you have a chance to read this, it is highly entertaining, and is highly exciting to learn about everything that in theory can be achieved by just rewiring our brains. However, be warned that it may be too easy to assume that everything can be achieved if we just try to rewire ourselves. Life is never that easy.
In a more recent story, at science daily we found a description of recent research with a more direct relationship between brain plasticity and mental illness coming out of the University of Oregon. The original research tries to link the relationship between changes in emotional wellbeing (such as reduction in stress, anxiety and depression) and changes in neuroplasticity. What the research seems to show is that if we meditate, (as opposed to just learn to relax) using a technique called Integrative Body Mind Training, and if we train in these technique long enough, our brain eventually learns how to keep this state of mind and changes its structure so it can respond to stressors in a more adequate way. For example, in the same article,  it is explained how students who learned those techniques, “showed lower levels of anxiety, depression, anger and fatigue than students in a control group” before a math test. The changes were associated with a specific part of the brain (the anterior cingulate cortex, which is connected with the amygdala and other midbrain structures usually associated with emotions). To make matters more interesting, it is explained that the anterior cingulate cortex is associated with several mental illness and emotional disturbances like attention deficit disorder, dementia, depression and schizophrenia.

Does this mean that we need to stop doing whatever we are doing and just start learning Integrative Body Mind Training? Probably not; I am sure we can use it in addition to whatever other medications/therapies/strategies are currently being used to recover from mental illness, but I do not think that anyone at this point will endorse shifting to this therapy while forgetting other options. There are many reasons why shifting is not a good idea. First of all, different individuals seem to respond in different ways to some therapies. I am sure many of us have experienced with medications or other types of home remedies in our daily encounters with fevers, cold or other illnesses, just to find out that what works fine for some individuals, do not necessarily work for us. Further, the research is still considered preliminary, and much more testing needs to be done to be considered as an alternative to other types of therapies. Why more testing? It could be possible that the individuals who were in the study were somehow predisposed to show better outcomes, because they knew that they were in a study. This is similar to the type of precautions that are taken when pharmaceutical companies are testing medications, and they found out that a sugar pill has the same effect that this very expensive medication that has taken years of research. Furthermore, if you have a chance to read Dr. Doidge’s book you’ll notice that his stories are based on individuals and not groups of people. If we want to be able to generalize to more than single individuals, we need to replicate the studies in multiple settings and across different types of people, to determine that the effects are not restricted to a specific type of people, or even worse, to some very unique characteristic that can only be found on a few individuals.

Although more testing needs to be done, this does not undermine the importance, excitement and potential that some of these findings bring to the field of mental health. Clearly, there is so much that we still need to learn about the brain and its connection to behavior, that it can be a little bit intimidating and perhaps overwhelming, especially when you feel that you need to know that now for your own personal reasons. On the other hand, it can be exciting to think about how much more we can learn about the relationship between our genetic makeup, the brain and the environment and how all three shape our behavior.

There are other types of meditation such as "sitting meditation" also called "mindfulness meditation" or "vipassana"/insight meditation that have long been utilized to address both emotional issues and health issues. We will discuss these practices in a future blog as they relate to both mental and physical health.

Research on Mental Health and Recovery from Mental Illness

We are the Research Institute at the Mental Health Center of Denver, and although technically we were just funded on May 2010, we have been doing research on mental health for the last 10 years.

We have been doing research in many areas associated with both Adults and Children's mental health. More recently however, we have concentrated our research on Recovery, Resiliency and Wellness in general. We have found that people outside the field of mental health, sometimes can confuse recovery from mental illness with recovery from substance abuse therefore, we are beginning to shift toward the word "wellness", which captures a lot of what is meant by recovery from mental illness.

Part of our research duties include to search for research in many places (including the internet), and since sometimes it is difficult to find good information, we decided to start this blog that will try to bring together research that we find interesting in areas associated with in mental illness and Recovery, Resiliency and Wellness.

We also maintain another blog where we speak much more about recovery from mental illness and substance abuse. If you are interested in learning more about those topics, and the impact it may have on everyday’s life, we invite you to visit our blog. If you are interested to learn about our research, we invite you to visit two of our websites: http://www.outcomesmhcd.com/ where we describe our work at MHCD in recovery, resiliency and wellness in both adults and children, as well as a current list of our publications and presentations. Or you can visit http://mhcdresearch.org/ where we present more of the services we can offer to centers and other entities interested in doing research and evaluation in recovery, resiliency and wellness, improving clinical practices, creating more effective and efficient use of clinical resources, mining clinical data, etc