SIMPLE STEPS Model for Suicide Risk Assessment

Introduction

The SIMPLE STEPS Model (McGlothlin, 2008) for suicide risk assessment provides a simple mnemonic similar to others like SADPERSONS (Patterson, et. al., 1983) or IS PATH WARM (from the American Association of Suicidology). Each of these is correlated with increasing suicide lethality and so this can be a useful short-hand to remember these items.

Suicide risk assessment on the crisis line is mostly concerned with imminent risk, and many suicide screeners designed for lay people may miss important variables in a goal to be simplistic; the SIMPLE STEPS model appears to avoid both of these traps, by providing an assessment tool simple enough to be used in the crisis line environment but comprehensive enough to be used by counsellors or therapists for ongoing monitoring of suicide risk.

Items in the SIMPLE STEPS Model

  • Suicidal – Is the individual expressing suicidal ideation?
  • Ideation – What is their suicidal intent?
  • Method – How detailed and accessible is their suicidal method?
  • Perturbation – How strong is their emotional pain
  • Loss – Have they experienced actual or perceived losses? (Relationships, material objects)
  • Earlier Attempts – What previous attempts has the individual experienced, what happened after those attempts?
  • Substance Use – Is the individual abusing drugs, alcohol, or other substances?
  • (Lack of) Troubleshooting Skills – Are they able to see alternatives or options other than suicide?
  • Emotions / Diagnosis – “Assessment of emotional attributes (hopelessness, helplessness, worthlessness, loneliness, agitation, depression, and impulsivity) and diagnoses commonly associated with completed suicide (e.g., substance abuse, mood disorders, personality disorders, etc.)” (McGlothlin, et. al., 2016)
  • (Lack of) Protective Factors – What is keeping this person safe from suicide? Who are their supports (internal such as personal values and external like people), resources and agencies
  • Stressors and Life Events – What has happened in their life to lead them to suicide?

Sharp readers will identify that these elements map very neatly onto the DCIB Model of Suicide Risk Assessment, but perhaps provide a better mnemonic in order to make sure that clinicians who do not have the DCIB in front of them are able to perform that assessment.

Validation of the SIMPLE STEPS Model

McGlothlin, et. al. (2016) used 13,000 calls over six years to a crisis line and correlated the SIMPLE STEPS items with the lethality risk present in that call. One limitation of this study is that it used self-reported (by the helpline worker taking the call) lethality rather than using another evidence-based risk assessment in order to compare with. I am satisfied that McGlothlin addressed this in his limitations section, where he noted the difficulty with using data collected in this manner.

References

McGlothlin, J. (2008). Developing clinical skills in suicide assessment, prevention and treatment.
Alexandria, VA: American Counseling Association

McGlothlin, J., Page, B., & Jager, K. (2016). Validation of the SIMPLE STEPS Model of Suicide Assessment. Journal Of Mental Health Counseling, 38(4), 298-307. doi:10.17744/mehc.38.4.02

Patterson, W.M., Dohn, H.H., Patterson, J. & Patterson, G.A. (1983). “Evaluation of suicidal patients: the SAD PERSONS scale.” Psychosomatics 24(4): 343–5, 348–9. doi:10.1016/S0033-3182(83)73213-5. PMID 6867245

Cite this article as: MacDonald, D.K., (2017), "SIMPLE STEPS Model for Suicide Risk Assessment," retrieved on May 29, 2017 from http://dustinkmacdonald.com/simple-steps-model-suicide-risk-assessment/.

 

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Suicide and Religion

Introduction

Studies on the connection between religion and suicide have led to mixed results. Some studies indicated higher levels of suicidality, no relation or reduced risk. Many of the studies that indicated a relationship (either positive or negative), had mediators attached – such as that individuals who were more religious were less likely to attempt suicide as long as they lacked other social supports.

Religiosity and Suicide

Meta-reviews, large scale analyses of suicide risk have helped shed some evidence on the connection between religion and suicide.

Lawrence, Oquendo & Stanley (2016) noted that suicide and religion are both complex dimensions (e.g. suicide ideation versus attempts versus death, religious affiliation versus attendance.) Being part of a majority religious community was found to be a greater protective factor against suicide than a minority community, but that attending religious services was not as important as having social supports (whether religious or not.)

Norko et. al. (2017) noted that all major faith communities (including Islam, Hinduism, Judaism, Buddhism, and Christianity) have strong objections to suicide.

In Lawrence et. al. (2016) a sample of clinically depressed patients in a hospital setting were found to have a higher rate of suicidality if they identified a religious affiliation, the more they attended religious services, and the more they indicated religion was important.

Finally, Wu, Wang & Jia (2015), analyzing over 5000 participants across several large studies identified the three elements that are responsible for the protective factor of suicide: being of a western culture, being older, and living in a area with religious homogeneity.

Spirituality and Suicide

Spirituality can be examined through a lens different from organized religion. While religion may entail specific doctrine, spirituality instead examines one’s relationship with “self, others and ‘God’” (Mandhoui, et. al., 2016), in whatever form that takes.

Mandhoui et. al. (2016) surveyed individuals who were in hospital for suicide attempts. Those individuals lower in spirituality were more likely to attempt suicide at 18 months, with “value of life” tending to reduce the chance that someone re-attempts.

Amato, et. al. (2016) noted that spirituality can be integrated into suicide prevention programs such as case management, therapy and suicide assessment to determine the impact for that individual. They summarize the impact of spirituality by noting that “some individuals at high risk of suicide may find fellowship in an affirming community of faith; others may be helped by rituals that confer atonement or a state of exaltation; still others may learn, through mindfulness meditation, to suspend their inclination to judge themselves harshly.”

Specific Religions / Denominations and Suicide

Buddhism and Suicide

Buddhism has received some exploration in the scientific literature, especially in light of Buddhist monks who have self-immolated for political reasons, the most famous of whom was Thích Quảng Đức in 1963, but research on the exact suicide rate, especially when considered with other religions is lacking.

Lizardi & Gearing (2010) noted several elements that may decrease suicide in Buddhist individuals, including that the largest communities of Buddhists (Asian Americans and Pacific Islanders) have lower suicide rates than whites (who tend to belong to different religious communities) and a strong aversion to killing. In contrast, a belief in reincarnation and life-after-death may contribute to an increase in the suicide rate among specific individuals who adhere strongly to Buddhist traditions.

Catholicism / Protestantism and Suicide

Emile Durkheim in his 1897 work Suicide examined the suicide rates among Catholics and Protestants. He found that Catholics had much lower rates of suicide than Protestants and theorized that it was the result of social support provided in the Catholic community. Additional support was confirmed by Torgler & Schaltegger (2014) and Siegrist (1996) in a modern sample, who also found that church attendance reduced suicide.

Hinduism / Islam and Suicide

Ineichen (1998) examined a number of studies on Hinduism and Islam and consistently found that Muslims had much lower suicide rates than Hindus, focused on a variety of South Asian diaspora (such as individuals in the United Kingdom from other countries.)

Following up on this research, Thimmaiah et. al. (2016) explored a population of Muslims and Hindus in India and found that , while Muslims indicated more negative attitudes towards suicide which may help explain why they are less likely to attempt suicide.

Judaism and Suicide

Examining Jewish Israelis, Eliezer & Daniel (2012) found a rate of suicide lower in Jewish individuals than those who are Catholic or Protestant. Significantly, those with other risk factors for suicide (like veterans, immigrants or those who have experienced trauma) are at elevated at risk of suicide despite their religiosity.

Conclusion

After a review of the literature, it emerges that religious denominations and other factors can have an influence on suicide. Some religions have higher rates of suicide, and some have lower rates, which may be explained by the value system of those religions or the social support of those religions.

The suicide risk by religion, from highest to lowest is below:

  1. Protestant Christian
  2. Catholic Christian
  3. Jewish

Other religions with less well established data sets can be compared to each other, but not necessarily to other religions: Islam has a lower level of suicide than Hinduism, while Buddhism has a lower level of suicide than Native American spirituality.

References

Amato, J. J., Kayman, D. J., Lombardo, M., & Goldstein, M. F. (2016). Spirituality and religion: Neglected factors in preventing veteran suicide?. Pastoral Psychology, doi:10.1007/s11089-016-0747-8

Dyson, J., Cobb, M., Forman, D. (1997) The meaning of spirituality: a literature review. Journal of Advanced Nursing. 26(6). Retrieved on March 3, 2017 from http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2648.1997.00446.x/abstract doi: 10.1046/j.1365-2648.1997.00446.x

Durkheim, E. (1897). Le suicide: étude de sociologie. F. Alcan: Chicago, IL.

Eliezer, W., & Daniel, S. (2012). Suicide in Judaism with a Special Emphasis on Modern Israel. Religions, Vol 3, Iss 3, Pp 725-738 (2012), (3), 725. doi:10.3390/rel3030725

Ineichen, B. (1998). The influence of religion on the suicide rate: Islam and Hinduism compared. Mental Health, Religion & Culture, 1(1), 31.

Lawrence, R. E., Brent, D., Mann, J. J., Burke, A. K., Grunebaum, M. F., Galfalvy, H. C., & Oquendo, M. A. (2016). Religion as a risk factor for suicide attempt and suicide ideation among depressed patients. Journal Of Nervous And Mental Disease, 204(11), 845-850. doi:10.1097/NMD.0000000000000484

Lawrence, R. E., Oquendo, M. A., & Stanley, B. (2016). Religion and suicide risk: A systematic review. Archives Of Suicide Research, 20(1), 1-21. doi:10.1080/13811118.2015.1004494

Mandhouj, O., Perroud, N., Hasler, R., Younes, N., & Huguelet, P. (2016). Characteristics of spirituality and religion among suicide attempters. Journal Of Nervous And Mental Disease, 204(11), 861-867. doi:10.1097/NMD.0000000000000497

Norko, M. A., Freeman, D., Phillips, J., Hunter, W., Lewis, R., & Viswanathan, R. (2017). Can Religion Protect Against Suicide?. Journal Of Nervous & Mental Disease, 205(1), 9-14. doi:10.1097/NMD.0000000000000615

Siegrist, M. (1996). Church Attendance, Denomination, and Suicide Ideology. Journal Of Social Psychology, 136(5), 559-566.

Thimmaiah, R., Poreddi, V., Ramu, R., Selvi, S., & Math, S. (2016). Influence of Religion on Attitude Towards Suicide: An Indian Perspective. Journal Of Religion & Health, 55(6), 2039-2052. doi:10.1007/s10943-016-0213-z

Torgler, B., & Schaltegger, C. (2014). Suicide and Religion: New Evidence on the Differences Between Protestantism and Catholicism. Journal For The Scientific Study Of Religion, 53(2), 316-340. doi:10.1111/jssr.12117

Wu, A., Wang, J., & Jia, C. (2015). Religion and Completed Suicide: a Meta-Analysis. Plos ONE, 10(6), 1-14. doi:10.1371/journal.pone.0131715

Cite this article as: MacDonald, D.K., (2017), "Suicide and Religion," retrieved on May 29, 2017 from http://dustinkmacdonald.com/suicide-and-religion/.

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Suicide Awareness Presentation

IntroductionSuicide Presentation Slide

The following is a presentation I prepared in 2012 on Suicide Awareness for delivery at Durham College. It’s just been sitting on my hard drive since then, so I’ve made it available for other organizations that wish to provide suicide awareness presentations. The content is reproduced below, and you can download the slides here. Although the content takes a Canadian focus, I’ve noted US statistics where possible.

Agenda

  • About Me
  • A Note on Wording
  • Definitions
  • Suicide Statistics
  • Suicide True and False
  • Risk Factors for Suicide
  • Warning Signs for Suicide
  • How to Help
  • Support Networks
  • Case Study

About Me

  • Currently Director of Online Support & Communication @ Distress Centre Durham
  • Distress Centre Durham History
    • 1600+ hours of telephone experience
    • 600+ hours of online chat and text
    • Former Placement Student, Summer Student (x3)
  • Trainer Experience
    • Distress Centre Durham Basic Training
    • DCIB Suicide Risk Assessment
    • Online Chat and Text (ONTX) Training

Before we start…

  • People do not commit suicide
  • You commit a crime, you get committed to a psychiatric hospital
  • Instead, people who take their own lives are said to have suicided or alternately died by suicide, as one dies of lung cancer or a person is murdered.

Definitions

  • Suicide – Intentional taking of one’s own life
  • Suicidal ideation – Clinical term for suicidal thoughts
  • Parasuicide
    • A suicidal attempt that is designed to fail or be discovered
    • Not necessarily attention-seeking behaviour

What is a Crisis?

A crisis is any event that overwhelms someone’s coping mechanisms, those things a person does to solve or deal with a problem

Suicide Statistics

  • Suicide is the 2nd leading cause of death in Canada for 18-24 year olds (behind car accidents) (Statistics Canada, 2015)
  • More than 90% of suicide victims may have had diagnosable mental illness (Bertolote, et. al., 2004) – Note that there is still not consensus on this figure, it still makes an important point about mental health treatment for suicide
  • 21,115 people died by suicide in Ontario in 2005
  • The suicide rate is 12.7 per 100,000 males and 4.1 per 100,000 females in Ontario (Statistics Canada, 2014a)
  • The Aboriginal suicide rate is 11 times higher than the national average (Public Health Agency of Canada, 2011)

Risk Factors for Suicide (CDC, 2016)

  • Mental Illness
  • Clinical Depression, Borderline Personality Disorder (BPD), Schizophrenia all increase risk
  • Financial Difficulties
  • Bullying (+ Cyber-bullying) for young adults
  • Relationship Troubles
  • Academic / School Troubles
  • Legal Problems
  • History of Physical / Sexual Abuse
  • Bereavement Grief and Loss
    • Especially a suicide-related loss
    • Interrupted (or “Complicated” Grief)

Suicide True and False

(See: Common Suicide Myths)

  • Most suicides involve drugs or alcohol…True! Up to 70% percent of suicides involve alcohol or drugs (Pompili, 2010)
  • Talking about suicide can plant the idea in someone’s head False! Most people feeling suicidal want to talk about their feelings
  • Teenagers have the highest rate of suicide False! The highest risk population is 45-54 years of age in Canada (Statistics Canada, 2014b), and in the US (CDC, 2014)
  • The most common suicide method is pills False! The most common method (overall) is hanging (in Canada: Statistics, 2016); in the US it is firearm: Barber & Miller, 2014)
  • Most suicidal people leave notes False! Only about 30% of suicides leave notes (Shioiri, et. al., 2005)
  • Suicidal people want to die False! Most suicidal people don’t want to die, but want the pain to stop

Suicide Risk Factors vs. Suicide Warning Signs

  • Risk Factors are things that increase the likelihood someone will suicide because those things make coping more difficult
  • Warning signs are clues that a suicidal crisis may be imminent
  • It takes careful clinical examination by a trained mental health professional to determine a person’s level of risk in the medium and long-term

Suicide Warning Signs (AAS, n.d.)

  • Sudden Mood changes (either very happy or very sad)
  • Sudden appetite changes
  • Talking about life in the past tense
  • Telling people goodbye, tying up loose ends
  • Talking about suicidal acts, feeling hopeless or helpless
  • Making lethality statements (“I wish I could fall asleep and not wake up”)

How to Help

  • Listen!
  • Provide empathy
  • Refer to resources
  • Distress Centre (1-800-452-0688, 905-430-2522)
  • Durham College Counselling Services
  • Durham Mental Health Services
  • Other resources (e.g. spiritual)
  • Explore options
  • Build support network

Support Network

  • Three levels of support
    • Internal
    • External
    • Peripheral
  • Strong support network allows developing the resources that provides the strongest defence against suicide
  • Internal Supports
    • Things that we do ourselves to cope with stress
    • Examples include:
      • Journalling
      • Listening to music / Playing an Instrument
      • Running / Working Out / Exercise
      • Prayer / Meditation / Spirituality
      • Art
      • Yoga / Massage
      • Deep Breathing
      • Other Hobbies
  • External Supports
    • People in our “inner circle” we reach out to
    • Examples include:
      • Family
      • Friends
      • Pets
  • Peripheral Supports
    • Community agencies and others outside of our inner circle
    • Examples include:
    • Distress Lines (e.g. Distress Centre)
    • Family Doctors
    • Psychiatrists / Psychologists
    • Durham Mental Health Services
    • Clergy

Summary

  • Suicide is usually preventable
  • Asking about suicidal thoughts is the most important thing you can do
  • Never be afraid to reach out to a professional for help

Case Study

The original training included a case study derived from Distress Centre Durham training materials.

References

American Association of Suicidiology (AAS). (n.d.) “Warning Signs | American Association of Suicidology. Retrieved on August 24, 2016 from www.suicidology.org/resources/warning-signs

Barber, C.W., Miller, M.J. (2014) Reducing a Suicidal Person’s Access to Lethal Means of Suicide: A Research Agenda. American Journal of Preventive Medicine. 47(3S2):S264–S272

Bertolote, J. M., Fleischmann, A., De Leo, D., & Wasserman, D. (2004). Psychiatric Diagnoses and Suicide: Revisiting the Evidence. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 25(4), 147-155. doi:10.1027/0227-5910.25.4.147

Centers for Disease Control and Prevention (CDC). (2011) Web-based Injury Statistics Query and Reporting System (WISQARS). National Center for Injury Prevention and Control. Retrieved on August 24, 2016 from http://www.cdc.gov/injury/wisqars/index.html.

Centers for Disease Control and Prevention (CDC). (2016) Suicide: Risk and Protective Factors. Retrieved on August 24, 2016 from http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

Pompili, M., Serafini, G., Innamorati, M., Dominici, G., Ferracuti, S., Kotzalidis, G. D., … Lester, D. (2010). Suicidal Behavior and Alcohol Abuse. International Journal of Environmental Research and Public Health, 7(4), 1392–1431. http://doi.org/10.3390/ijerph7041392

Public Health Agency of Canada. The Human Face of Mental Health and Mental Illness in Canada 2006. Ottawa, ON: Public Health Agency of Canada,  2011. Available at: http://www.phac-aspc.gc.ca/publicat/human-humain06/

Shioiri, T., Nishimura, A., Akazawa, K., Abe, R., Nushida, H., Ueno, Y., & … Someya, T. (2005). Incidence of note-leaving remains constant despite increasing suicide rates. Psychiatry & Clinical Neurosciences, 59(2), 226-228. doi:10.1111/j.1440-1819.2005.01364.x

Statistics Canada. (2014a) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on August 24, 2016.

Statistics Canada. (2014b) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on August 24, 2016.

Statistics Canada. (2015) Table 102-0561 – Leading causes of death, total population, by age group and sex, Canada, annual, CANSIM (database). Retrieved on August 24, 2016.

Statistics Canada. (2016) Navaneelan, T. Suicide rates: An overview. Retrieved on August 24, 2016 from www.statcan.gc.ca/pub/82-624-x/2012001/article/11696-eng.htm

Cite this article as: MacDonald, D.K., (2016), "Suicide Awareness Presentation," retrieved on May 29, 2017 from http://dustinkmacdonald.com/suicide-awareness-presentation/.
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Interprofessional Education in Suicide Prevention

Introduction to Interprofessional Education

This is an essay I wrote in 2015 for the course HSRV 306 Critical Reflection for Practice at Athabasca University.

Interprofessional education (IPE) is defined as “the process, through which two or more professions learn, with, from and about each other to improve collaboration and the quality of service” (CAIPE, 1997) IPE has been practiced in various forms for decades (Smith & Clouder, 2010) but is most commonly associated with healthcare and the social sciences.

The advantage of interprofessional education is that it allows allied fields to benefit from “pooling together of expertise in teams [that] would make them more effective and efficient” (Illingworth & Cheivanayagam, 2007) than those professions working on their own. As there is much overlap in the work provided by professionals in social work, psychology and psychiatry this pooling together of resources has the potential to improve their skills and competencies.

One competency required by these professions is the ability to prevent suicide, which involves the interrelated skills of risk assessment and suicide intervention. How much an individual may need to intervene will differ depending on their role, with some professionals needing only to recognize the signs and refer them on, while others may be required to perform regular and comprehensive suicide risk assessment and intervention.

Suicide and Mental Health Professionals

The suicide rate in Canada has remained relatively steady in Canada for several years, with more than 3,000 individuals dying by suicide in Canada each year. (Statistics Canada, 2014) A 2002 meta-review demonstrated that many of these people visited physicians or nurses for physical health complaints before their death. (Luoma, Martin & Pearson, 2002) Whether or not these physical complaints were related to their mental health issues or not, an opportunity for suicide screening and subsequent referral was missed.

One study on suicide screening, focused on Emergency Departments in the United States found that when universal screening was implemented, requiring all patients to be screened for suicide regardless of their presenting problem, the rate of detected suicidal thoughts doubled. (Boudreaux, et. al., 2015) This demonstrates the importance of all healthcare professionals being competent in the basics of suicide screening.

Mental health professionals regularly treat suicidal clients, with Feldman & Freedmanthal’s 2006 study reporting 78% of social workers had provided service to a suicidal client in the previous year. While mental health professionals regularly work with suicidal clients they may lack the skills or confidence to respond appropriately.

Ruth et. al. (2006) conducted interviews with social work students, faculty and Deans and discovered that the majority of programs provided their social worker students less than 4 hours of education on suicide assessment during their graduate programs. This resulting lack of coverage left social work students feeling unconfident working with suicidal clients, and indeed scared of the possibility that a client will reveal suicidality, a fact noted by other researchers as well. (Osteen, Jacobson & Sharpe, 2014) This paralyzing fear may contribute to burnout or other negative professional consequences and ultimately make them less effective practitioners.

Interprofessional education has the potential to improve the care of suicidal clients by allowing professionals to take advantage of the best practices in education present in allied fields. By borrowing best practices from other helping professions the number of competent professionals may ultimately be increased and the number of suicides or potential suicides that are undetected may be reduced.

Potential drawbacks to adopting interprofessional education that have been documented in the literature include the costs of implementation (such as redesigning curriculums) and the possible loss of professional identity among different groups who learn the same skills (Smith & Clouder, 2010) Given that mental health care is already well-diffused (with each professional area like social work, psychology and psychiatry having specialties but ultimately all being able to provide counselling or therapy with training), this may be less of an issue in suicide prevention, which is currently practiced by volunteers all the way up to Psychiatrists and Psychologists holding doctorates.

Interprofessional Education in Physical and Mental Health

There are a number of approaches to education in mental health fields (social work and psychology) and physical health fields (nursing and non-psychiatric medicine), including best practices that have demonstrated improved knowledge transfer, satisfaction and skill within their respective professional programs.

Physical health professions include general medicine practiced by physicians as well as nurses, who are recognized as professionals in their own right (College of Registered Nurses of Manitoba, n.d.). Professional schools of nursing have a long history, stretching back to the early 1900s (Schekel, 2009), while the first medical school opened in Italy in the 9th century. (de Divitiis, Cappabianca, & de Divitiis, 2004)

Education of physicians and nurses has always emphasized hands-on treatment and “learning by doing”, but especially since the 15th century when the first cadaver dissections were performed for medical students. (Rath & Garg, 2006)

Current techniques used in medical and nursing education include case studies, where the signs and symptoms of an illness and a patient’s history are described in detail and a diagnosis or treatment is sought (Raurell-Torreda, et. al., 2015), and simulated patients who are specially trained actors that medical students interact with in order to experience conducting clinical interviews, assessment and diagnosis (Uys & Treadwell, 2014).

Both case studies and simulated patients have shown utility in general nursing and medicine according to Luebbert & Popkess (2015). Some studies have specifically explored their utility with suicidal patients, such as Norrish (2009) who used cases to teach suicide risk assessment skills to Omani medical students.

Techniques that have demonstrated effectiveness with Psychology and Social Work students on the other hand, include role-playing (Murdoch, Bottorff & McCullough, 2013) where students practice simulated complaints with each other in order to develop the skills of recognizing and responding to suicidal statements, and evidence-based lecture. (Scott, 2015)

Gate-keeper training programs that are designed to teach lay people the basic skills of recognizing the signs of suicide and referring individuals to trained professionals, for instance, QPR (Lancaster, et. al., 2014) have demonstrated effectiveness in increasing confidence and skill in both nursing (Bolster, Holliday, Oneal & Shaw, 2015) and social work students. (Sharpe, Frey, Osteen & Bernes, 2014)

While domain-specific education for nurses and physicians has begun to be developed, it lacks the exploration of knowledge-transfer and rigorous methodology necessary for it to be as effective as possible. One example of beginning nurses education is Kishi et. al. (2014), who had emergency room nurses in Japan completing a 1 day workshop. The workshop covered suicide risk assessment, management of the immediate suicidal crisis, referring patients to long-term resources, and attitudes towards suicidal patients. This workshop was taught using lectures and case studies, with a pre and post-test design on a scale measuring attitudes towards suicide (but not knowledge transfer or skill acquisition.) The lack of a knowledge-transfer component means these nurses are unable to demonstrate whether they learned anything or if they apply their training to their patients.

Other exercises in integrating suicide prevention into social work including Scott (2015) who developed a full-semester course for MSW students that taught suicide risk assessment, intervention, and public health interventions such as media guidelines around suicide. Luebbert & Popkess (2015) had students complete either a video-taped lecture or speak to a standardized patient after being exposed to material on suicide assessment and found that the group that worked with the standardized patient felt much more confident.

What is lacking in nursing and medical education is a focus on evidence-based practice in suicide prevention, an issue noted by nursing faculty (Kalb et. al., 2015) Additionally providing opportunities for hands-on practice through exercises like case studies, simulated patients, and roleplaying will allow for necessary deep knowledge transfer.

Conclusion

Suicide prevention is a field ripe for improvement by integrating the best practices from a variety of allied fields. Most notably, from nursing and general medicine the case study and simulated/standard patients may help social workers and psychologists reduce their fear of working with suicidal clients, while the strong evidence-based lecture, roleplaying and gate-keeeper training may give busy nurses and physicians an opportunity to develop suicide awareness and referral skills that will allow them to intervene to prevent death.

References

Bolster, C., Holliday, C., Oneal, G., & Shaw, M. (2015). Suicide Assessment and Nurses: What Does the Evidence Show?. Online Journal Of Issues In Nursing, 20(1), 1-1 1p. doi:10.3912/OJIN.Vol20No01Man02

Boudreaux, E., Allen, M., Goldstein, A.B., Manton, A., Espinola, J. & Miller, I. (2015) Improving Screening and Detection of Suicide Risk: Results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Effectiveness Trial. Society for Prevention Research 23rd Annual Meeting. Accessed Dec 10 2015 from https://spr.confex.com/spr/spr2015/webprogram/Paper23206.html

de Divitiis, E., Cappabianca, P. & de Divitiis, O. (2004) The “schola medica salernitana”: the forerunner of the modern university medical schools. Neurosurgery. 55(4);722-44

CAIPE (1996) Principles of Interprofessional Education. London: CAIPE.

College of Registered Nurses of Manitoba. n.d. “Standards of Practice for Registered Nurses: Nursing Practice Expectations” Accessed electronically from https://www.crnm.mb.ca/uploads/document/document_file_89.pdf?t=1438266260 on Dec 11 2015.

Feldman, B. N., & Freedenthal, S. (2006). Social work education in suicide intervention and prevention: An unmet need? Suicide and Life-Threatening Behavior. 36. 467–480

Illingworth, P. & Chelvanayagam, S. (2007) Benefits of interprofessional education in health care. British Journal of Nursing. 16(2):121-4

Kalb, K.A., O’Conner-Von, S.K., Brockway, C., Rierson, C.L. & Sendelbach, S. (2015) Evidence-Based Teaching Practice in Nursing Education: Faculty Perspectives and Practices. Nursing Education Perspectives. DOI: 10.5480/14-1472

Kishi, Y., Otsuka, K., Akiyama, K., Yamada, T., Sakamoto, Y., Yanagisawa, Y., Morimura, H., Kawanishi, C., Higashioka, H., Miyake, Y. & Thurber, S. (2014) Effects of a Training Workshop on Suicide Prevention Among Emergency Room Nurses. Crisis. 35(5):357–361 DOI: 10.1027/0227-5910/a000268

Lancaster, P.G., Moore, J.T., Putter, S.E., Chen, P.Y., Cigularov, K.P., Baker, A., Quinnett, P. (2014) Feasibility of a web-based gatekeeper training: implications for suicide prevention. Journal of Suicide and Life Threatening Behaviour. 44(5):510-23. DOI: 10.1111/sltb.12086

Luebbert, R. & Popkess, A. (2015) The Influence of Teaching Method on Performance of Suicide Assessment in Baccalaureate Nursing Students. Journal of the American Psychiatric Nurses Association. 21(2) 126-133. DOI: 10.1177/1078390315580096

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Cite this article as: MacDonald, D.K., (2016), "Interprofessional Education in Suicide Prevention," retrieved on May 29, 2017 from http://dustinkmacdonald.com/interprofessional-education-suicide-prevention/.
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What is Nu-Rekall Mind Science?

Introduction

As a supporter of evidence-based treatment (EBT), and someone who endeavours to cite my sources and back up my claims wherever possible, I find the lack of science in some circles really frustrating. I recently stumbled upon an organization called International Suicide Prevention run by Matthew D. Dovel that makes very fantastic claims about the effectiveness of a treatment or set of treatments called “Nu-Rekall” on mental health and suicide, unmatched by any other treatment and without any peer reviewed studies to support their efficacy.

Naturally, my curiosity was piqued, but the Nu-Rekall treatment is vague and the proprietor, as I explain below, appears not to have the background necessary to treat mental health disorders. My hope with this article is to stimulate discussion on EBT, and to publicly challenge Mr. Dovel to bring his work in-line with established best practices.

All the quoted content below is used within the DMCA and 17 U.S.C. § 107 on Fair Use in the United States and § 29.1 of the Copyright Act of Canada.

Matthew D. Dovel

Matthew Dovel says on his website that he is a suicide prevention expert. He also says he is a scientist. Everyone has different criteria for that word, but I would define a scientist as someone who contributes to the body of knowledge in a field through academic scholarship, like publishing in a journal.

His academic education includes:

  • Charter College-Anchorage (2 years), took Computer Aided Drafting (CAD)
  • University of Nevada-Las Vegas (3 years), majored in Civil Engineering and minored in Psychology and Business. It’s unclear if Dovel earned a degree here.
  • Palomar College (2 years), he indicates mostly computer-related topics but may have taken a couple Psychology courses

In addition to these formal educational pursuits Dovel also notes PSI Seminars and other self-help workshops. There is no evidence that he has participated in any training or education related to Social Work, Psychology, Medicine or an allied field relevant to mental health, nor has he indicated any evidence-based training in suicide intervention like Applied Suicide Intervention Skills Training (ASIST), QPR, or others.

Since March 2015, Dovel has sat on the Editorial Board of the prestigious-sounding International Journal of Emergency Mental Health and Human Resilience which is published by OMICS Group. That someone can sit on an editorial board with no graduate study or published literature themselves is worrisome. That journal is not indexed by PubMed or other reputable warehouses for scientific data, like most of the OMICS Group journals.

His LinkedIn proclaims that “There is no one better than I am at preventing suicides!”, I have my doubts.

Dovel has written a book called “Life After Death” chronicling two Near Death Experiences (NDE). It appears to be these NDE, not his suicide prevention work, that led him to be profiled on Good Morning America (you can see that interview here), A&E and 20/20. This is clearly stated on his LinkedIn in the publications section, but is less clear in other areas, such as the about page of his organization ISP (detailed below) where he states under a column about partnerships with ISP “As seen on:CBS, NBC, ABC, FOX, ESPN, Coast to Coast, Good Morning America, 20/20,.” This is very misleading.

Some of his other (self) publications include:

Other potentially misleading items include an article titled “Psychology Today: Abstract – New Treatments that Cure Suicidal Ideation“. This article has no connection to the magazine Psychology Today but rather that is part of the article’s title.

International Suicide Prevention (ISP)

International Suicide Prevention is Dovel’s charity. It is a registered 501(c)(3) non-profit (EIN#20-4671131), though its Form 990 indicates less than $25,000 in revenue.

On the contact page, there is an opportunity to buy posters promoting ISP with their 24/7 helpline number (which Dovel claims he answered himself for 10 years.) There is no attribution indicating he has permission to use the intellectual property of Fox, which owns the rights to the Fry character from the TV series Futurama. Update: Dec-20-2016: This image has been removed, though other potentially infringing images may remain.

On the page for law enforcement targeted initiatives, Dovel notes that his Suicide Prevention Guide Booklet has been “endorsed by mental health professionals, doctors, and advanced behavioral studies experts as a viable solution to drastically reduce suicide rates.” Although he does list one endorsement by a Psychologist in the back of the handbook, the other individual listed is a neurolinguistic programming practitioner. There is insufficient evidence to support the efficacy of NLP (Sturt, et. al., 2012).

On an ISP page listing endorsements Dovel lists an orthopedic surgeon (Andrea E. Salvi) as endorsing his material. This surgeon is also a Board Member of an OMICS Group Journal, and appears to have has no professional experience in psychology or suicide. I can find no evidence to support Salvi’s assertion that he has performed any work for the US military.

Nu-Rekall

Nu-Rekall (trademarked) is the basis for the treatments that Dovel promotes. The website claims that “Nu-Rekall™ has self-help procedures that are completely autonomous removing suicidal ideation permanently.” Dovel does not link to any peer-reviewed studies evaluating his techniques. Dovel claims he helps over 200 individuals daily, but as this page suggests, he is likely counting every visitor to his website as a client he has delivered service to.

He charges nearly $5,000 on his website for training in his Nu-rekall methods.

4 Phase Model

Dovel does actually describe his 4 phase model on one page. I’ve paraphrased it here to the best of my ability.

  1. The client should ask themselves how long they’ve been suicidal and what occurred at the time those suicidal thoughts started?
  2. Next, because the treatment can cause amnesia, the client fills out a questionnaire about the event that triggered the suicidal thoughts and its emotional intensity
  3. Now the client imagines the event occurring again, but changes details about it (such as altering the weather)

No peer-reviewed studies are provided to explain why this movement technique is supposed to have any impact on one’s suicidality or emotional state, and ignores that for many people suicidal thoughts are not caused by a single distressing event but rather a constellation of risk factors, with no identifiable cause at all (see the Suicide Prevention Resource Centre’s list of suicide risk factors, the majority of which are not negative life events.)

Suicide Prevention Guide Booklet (SPGB)

This booklet (running 32 pages with wide margins and a large font) includes two ad spaces, both unused. Rather than go through the book line by line I’ve picked out some quotes for commentary.

“it takes fewer muscles to smile than to get angry according to Japanese’s” (this article confirms the origins of the concept that it takes fewer muscles to smile than to frown are uncertain; there’s no evidence suggesting they are Japanese.)

“Education has been shown to be the best method for reducing suicide rates.” Certainly, training gatekeepers is important. But educating clients themselves in methods of self-help has a limited contribution to the suicide rate when compared to broad community interventions that works on multiple levels, as Fountoulakis, Gonda, & Rihmer (2011) explain.

“According to scientific research humans have only two core emotions: love, and fear.” This is also incorrect. It used to be thought that there were 6 core emotions (anger, fear, surprise, disgust, happiness and sadness), although research from the University of Glasgow (Jack, Garrod & Schyns, 2014) suggests four (anger, fear, happiness, sadness.)

Russell (2003; 2009) conceptualizes “core affect” as the idea of feeling either good or bad – but there are no studies that I could find indicating two core emotions of love and fear.

“At the University of Berkley, California a study was done on a group of Manic Depressants with just the following self-therapy for one year. At the end of the year ALL were declassified as Manically Depressed.” Note the spelling errors and the use of the outdated term “manic depressive” (manic depression was replaced in the DSM-III in 1980 with “bipolar disorder”) while person-centered language would suggest calling the participants “people with bipolar disorder” instead. There’s is no citation listed and I would doubt if any such study ever existed.

“Top two reasons for a suicide attempt[:] The sudden change of status for an individual’s: romantic, and/or financial situation.” While there is support to the idea that relational changes commonly precede a suicide attempt (e.g. Yen et. al., 2005; Bagg, Glenn & Lee, 2013; Conner, et. al., 2012) that is because social support is an important buffer to suicide. (Gonçalves, et. al., 2014; Kleiman, Riskind, & Schaefer, 2014; Farrell, Bolland & Cockerham, 2014; Kleiman, et. al., 2012; Hirsch & Barton, 2011)

While Hempstead & Phillips (2015) notes that financial issues can lead to suicide, “mental illness, health problems, and other personal issues [and] access to lethal means also importantly affects suicide risk.” It appears that financial issues only commonly precede suicide in middle age.

Near the end is an “EMR” (Emotional Memory Removal) chart that requires an individual to think about a strong emotion while raising or lowering their hands (the chart indicates when to do which) and saying a number out loud, and then repeating the process but raising an arm and a leg. No sources are provided for why this would be effective.

Dovel’s Study

I reached out to Dovel for some clarification on the evidence-base for his work. He responded linking me to some of the sources that you see above. He also linked me to this suggested evaluation of his techniques.

The way the study appears to be constructed was that Dovel would have each participant rate their suicidal thoughts on a scale of 1-10. Then they would perform the Nu-Rekall procedures and receive a follow up call at 1 week, 1 month and 6 months to determine if the level of their intensity increased or decreased, and whether they had demonstrated any suicidal behaviour.

There are a number of methodological issues with this study that would prevent it from being accepted for peer review. Just a few that come to mind:

  • He indicates he had 500 volunteers (gender-matched exactly 50/50), but he only started with 60. Each month he surveyed other callers for a total of 500 surveys. If that’s the case, there is not 6 months of continuous data (as in a longitudinal design) for 500 people, there is 6 months of data for 60 people, severely limiting the usefulness of the large sample size.
  • There is a failure to define intensity (how do you verify a change if you’re not defining the variables?)
  • There is a failure to define suicidal behaviour or how he determined there was no recurrence in suicidal behaviour
  • There is a failure to control for the impact that emotional support from any helper would provide (a control group where someone received supportive check-ins without doing Nu-Rekall would have showed this)

Best Practices and Recommendations

I invite Dovel to follow some recommendations for himself, his website and the Nu-Rekall program. These include:

  • Taking a proper suicide intervention training like ASIST so that he can incorporate the evidence-base into his literature
  • Change references to the ISP helpline number to the National Suicide Prevention Lifeline (1-800-273-8255) until such time as Dovel has completed helpline training through an NSPL or AAS-accredited crisis line. This will ensure he is competent to perform suicide risk assessment
  • Consider completing the AAS Crisis Worker certification
  • Write up a proper proposal for a study of the Nu-Rekall techniques that includes repeatable methods, proper controls, and results and then having that study performed by an independent third party
  • Get that study peer-reviewed and published in a PubMed-indexed journal to open it to critique
  • Remove references to media like Good Morning America and 20/20 from the ISP websites so that visitors are not misled into thinking those appearances were related to suicide prevention work; make it clear those appearances were focused on near-death experiences
  • Provide citations for claims throughout existing pamphlets (like the UC Berkeley study noted above)

References

Bagge, C. L., Glenn, C. R., & Lee, H. (2013). Quantifying the impact of recent negative life events on suicide attempts. Journal Of Abnormal Psychology, 122(2), 359-368. doi:10.1037/a0030371

Conner, K. R., Houston, R. J., Swogger, M. T., Conwell, Y., You, S., He, H., & … Duberstein, P. R. (2012). Stressful life events and suicidal behavior in adults with alcohol use disorders: Role of event severity, timing, and type. Drug & Alcohol Dependence, 120(1-3), 155-161. doi:10.1016/j.drugalcdep.2011.07.013

Sturt, J., Ali, S., Robertson, W., Metcalfe, D., Grove, A., Bourne, C., & Bridle, C. (2012). Neurolinguistic programming: a systematic review of the effects on health outcomes. The British Journal Of General Practice: The Journal Of The Royal College Of General Practitioners, 62(604), e757-e764. doi:10.3399/bjgp12X658287

Farrell, C. T., Bolland, J. M., & Cockerham, W. C. (2014). Original article: The Role of Social Support and Social Context on the Incidence of Attempted Suicide Among Adolescents Living in Extremely Impoverished Communities. Journal Of Adolescent Health, doi:10.1016/j.jadohealth.2014.08.015

Fountoulakis, K. N., Gonda, X., & Rihmer, Z. (2011). Review: Suicide prevention programs through community intervention. Journal Of Affective Disorders, 13010-16. doi:10.1016/j.jad.2010.06.009

Gonçalves, A., Sequeira, C., Duarte, J., & Freitas, P. (2014). Suicide ideation in higher education students: influence of social support. Atencion Primaria, 46(Supplement 5), 88-91. doi:10.1016/S0212-6567(14)70072-1

Hempstead, K. A., & Phillips, J. A. (2015). Research Article: Rising Suicide Among Adults Aged 40–64 Years. The Role of Job and Financial Circumstances. American Journal Of Preventive Medicine, 48491-500. doi:10.1016/j.amepre.2014.11.006

Hirsch, J. K., & Barton, A. L. (2011). Positive Social Support, Negative Social Exchanges, and Suicidal Behavior in College Students. Journal Of American College Health, 59(5), 393-398. doi:10.1080/07448481.2010.515635

Jack, R. E., Garrod, O. G., & Schyns, P. G. (2014). Dynamic Facial Expressions of Emotion Transmit an Evolving Hierarchy of Signals over Time. Current Biology, (2), 187. doi:10.1016/j.cub.2013.11.064

Kleiman, E. M., Riskind, J. H., & Schaefer, K. E. (2014). Social Support and Positive Events as Suicide Resiliency Factors: Examination of Synergistic Buffering Effects. Archives Of Suicide Research, 18(2), 144-155. doi:10.1080/13811118.2013.826155

Kleiman, E. M., Riskind, J. H., Schaefer, K. E., & Weingarden, H. (2012). The moderating role of social support on the relationship between impulsivity and suicide risk. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 33(5), 273-279. doi:10.1027/0227-5910/a000136

Russell, J.A. (2003) Core Affect and the Psychological Construction of Emotion. Psychological Review. 110(1). 145-172. DOI: 10.1037/0033-295X.110.1.145

Russell, J. A. (2009). Emotion, core affect, and psychological construction. Cognition & Emotion, 23(7), 1259-1283. doi:10.1080/02699930902809375

Yen, S., Pagano, M. E., Shea, M. T., Grilo, C. M., Gunderson, J. G., Skodol, A. E., & … Zanarini, M. C. (2005). Recent Life Events Preceding Suicide Attempts in a Personality Disorder Sample: Findings From the Collaborative Longitudinal Personality Disorders Study. Journal Of Consulting And Clinical Psychology, 73(1), 99-105. doi:10.1037/0022-006X.73.1.99

Cite this article as: MacDonald, D.K., (2016), "What is Nu-Rekall Mind Science?," retrieved on May 29, 2017 from http://dustinkmacdonald.com/nu-rekall-mind-science/.

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