Psychologist taking patients off suicide precaution.

[cara susanna]

While we may train for 8 years to be psychiatrists, only about 12-18 weeks of those first four years are in psychiatric topics. While understanding medicine is very helpful for psychiatry in general (the number of medical illnesses we come across masquerading as psychiatric illnesses that were missed by the medical team in a given month is usually firmly in the double digits), very little of that time will help in any way whatsoever with the assessment of a suicidal patient.

Though I disagree on the taking things at face value bit. If I had a dollar for every time someone told me with a straight face they weren't using and they popped positive for drugs I would be far better off financially, to give but one example.

Here's the thing. I'm not sure I'd feel comfortable involuntarily hospitalizing someone who's denying suicidality just because I have a suspicion that they may be lying. Taking away someone's liberty, to me, is a fairly big deal and I worry that this could turn into some kind of Thomas Szasz-y nightmare. Especially given what we know about hospitalization not actually being helpful for suicidality.

Similarly, I'm not sure that I could refuse hospitalization for someone just because I suspect they may not actually be suicidal if they're saying that they are. One of the limitations of our field is having to rely on self-report, and although we do what we can to get around that (e.g., collateral information) we aren't mind readers or soothsayers and we never will be.

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[PsyDr]

@Mad Jack

I think we all make clinical interpretations on the available data. And what you’re doing makes sense to some degree.

The point is that the data doesn’t really support that you are better at lie detection. And honestly, I don’t think you really believe that you are better. If you did, you’d be in Vegas or consulting for fortune 10 companies or in lawsuits starting at 9 figures.

 

[Justanothergrad]

I find it interesting that the qualifier 'well trained' was needed for psychologists and not for physicians when it comes to mental health issues. Variability in training is likely the result of greater variability in employment settings/employment tasks. I'm not sure speculation supports the notion that only those trained in a certain setting (repeatedly identified as ER in this thread) is the only way to learn suicide assessment. SI is a transdiagnostic behavior and, as such, presents across settings.

Length of stay for those with SI/SA is closer to 6/7 days.

Length of Stay and Readmission Rates of Patients Admitted with a Diagnosis of Suicidal Ideation or Suicide Attempt, 2010-2014

Researchers evaluated the demographic, clinical, and health resource utilization profile of patients hospitalized with suicidal ideation or suicide attempt to understand their unmet needs.

www.psychcongress.com

Otherwise, I find it interesting that talk of SI morphed to talk of addiction in order to make the point about 'lie detection', which we suck at.

 

[PsyDr]

Otherwise, I find it interesting that talk of SI morphed to talk of addiction in order to make the point about 'lie detection', which we suck at.

The point of the article was that psychiatrists > psychologists at suicide assessment. The popular press articles indicate that Epstein admitted to other inmates that he lied to providers. Lie detection then becomes a significant part of the debate.

 

[foreverbull]

Here's the thing. I'm not sure I'd feel comfortable involuntarily hospitalizing someone who's denying suicidality just because I have a suspicion that they may be lying. Taking away someone's liberty, to me, is a fairly big deal and I worry that this could turn into some kind of Thomas Szasz-y nightmare. Especially given what we know about hospitalization not actually being helpful for suicidality.

Similarly, I'm not sure that I could refuse hospitalization for someone just because I suspect they may not actually be suicidal if they're saying that they are. One of the limitations of our field is having to rely on self-report, and although we do what we can to get around that (e.g., collateral information) we aren't mind readers or soothsayers and we never will be.

I agree with this and would also add that coming from the viewpoint of seeing adults in private practice, there is usually little (current) collateral info to go off of. Level of consultation with other health professionals will vary by practitioner, but some folks come in without prior experience, don’t see a psychiatrist concurrently, don’t identity prior practitioners (or don’t remember names), or their prior experience with the mental health system was brief or was many years ago. In my experience in private practice, much of the time their word and prior behaviors in therapy are all I have as data.

Perhaps this is also because I am a woman and more vigilant about personal safety, but I think of my own physical safety immediately when I think about doing ANYTHING against a male client’s will in therapy based on prior experiences of intimidation by male clients in other settings. You can’t always predict how people will handle being told they have no choice, hence part of the challenge of involuntary hospitalization (or suicide watch protocol).

 

[Justanothergrad]

The point of the article was that psychiatrists > psychologists at suicide assessment. The popular press articles indicate that Epstein admitted to other inmates that he lied to providers. Lie detection then becomes a significant part of the debate.

I understand how it happened. My point is that it serves zero purpose except to confuse the issue at hand in the thread. The issue is discussion of risk assessment. I don't see how focusing on a different diagnostic spectra supports effective empirical discussion of suicide assessment. If we want to talk about the veracity and utility of assessment in general, fine we can do that I suppose. But clearly the contextual factors and motivational factors for suicide and substance are different, so why pretend that they aren't or that these are the same sorts of assessments/outcomes.

 

[DynamicDidactic]

My general impression is that psychologist training is far more variable than psychiatrist training, so some psychologists likely have quite robust exposure to suicide risk assessment in emergency and correctional settings while others have far less, depending on the quality of the included rotations within a program, but that most programs provide adequate training in this regard.

Agreed. In general, doctoral psychology programs differ immensely in training. Variability works both ways, some will be poorly trained and some will spend years researching and working with individuals at high-risk for suicide.

Do psychologists have years of training in inpatient and emergency psychiatry that would prepare them specifically for the sort of risk assessment required of a patient like this?

Some do. Not all.

Most of my patients lie because they want to attempt again,

I am sure this is setting-specific and people have different motivations depending on the setting. I've worked with individuals that lie the other way around (e.g., homeless folks in a Chicago winter that need shelter and inpatient units are much nicer that homeless shelters).

I would love to test the statement that most lie. I tend to not rely on individual experiences, which are far too biased.

learning to read which ones are and are not BSing you is an art more than a science and really requires structured training to develop a decent degree of skill with regard to.

I tend to question health decisions that are made on the basis of art more than science. Vice versa, I prefer entertainment that relies on art more than science.

If I had a dollar for every time someone told me with a straight face they weren't using and they popped positive for drugs I would be far better off financially, to give but one example.

Let us stay away from straw man arguments. We are talking about the ability to work with suicide and assess suicide risk.

I enjoy the psychiatry forum on SDN because there are many similar scientifically-minded posters. I wonder how many people would agree with you on the manner in which we figure out how to do suicide assessments, particularly for risk. It is likely that you are indeed a very effective clinician that can assess validity of suicide risk. However, do you trust every other psychiatrist - even those that had similar training to you - to figure out the art of assessment on their own? Or would you rather base this on some more objective empirical evidence?

 

[foreverbull]

I wonder how many people would agree with you on the manner in which we figure out how to do suicide assessments, particularly for risk. It is likely that you are indeed a very effective clinician that can assess validity of suicide risk. However, do you trust every other psychiatrist - even those that had similar training to you - to figure out the art of assessment on their own? Or would you rather base this on some more objective empirical evidence?

I think this is the crux of the issue: because one's word is objective evidence, and the rest is non-measurable, this is how we honor personal choice and cover our own butts in practice when someone is at risk of harm to self--by relying on self-report.

@Mad Jack I hear what you're saying about understanding nuance/nonverbals/etc. (that is just good interpersonal skills, which I hope all risk assessors have), but to follow this to the extreme, I would hate to be sued for being told that I must have missed some kind of nonverbal cue that indicated that the client was unable to keep himself/herself safe when the patient himself/herself denied danger to self (and as DynamicDidactic says, how do we train this type of risk assessment and set the threshold at which to overrule the client's words/self-report? It sounds very complicated and nuanced, which will translate to training that is not standard).

Either way, fundamentally I don't believe practitioners should be held accountable when assessing risk if they've done it "right" but a client was set on ending his/her/their own life and "faked good." These situations are usually rare, because in my experience, most clients readily admit to feeling bad and want to do anything to feel better (most just want the pain to end, not their lives), but there's a few folks out there who are in the Epstein realm of probably having nothing left to hope for. It's sad, but it's also a personal choice.

 

[Mad Jack]

Here's the thing. I'm not sure I'd feel comfortable involuntarily hospitalizing someone who's denying suicidality just because I have a suspicion that they may be lying. Taking away someone's liberty, to me, is a fairly big deal and I worry that this could turn into some kind of Thomas Szasz-y nightmare. Especially given what we know about hospitalization not actually being helpful for suicidality.

Similarly, I'm not sure that I could refuse hospitalization for someone just because I suspect they may not actually be suicidal if they're saying that they are. One of the limitations of our field is having to rely on self-report, and although we do what we can to get around that (e.g., collateral information) we aren't mind readers or soothsayers and we never will be.

I respect your view on it, and I'm actually very much of the same opinion most of the time. But very often, I will have to play detective with regard to my patients, contacting family, friends, local police, etc depending on the case and in accordance with the patient's permission and the law. Often the collateral evidence will contradict the patient's statements, and that is where they often get committed due to risk and a preponderance of evidence. It's hard for me to let a guy go that is saying he isn't suicidal when I've got a note, video evidence, and family all telling me they have a very clear plan and intent to end their lives. Similarly, we have very limited beds and a very large population that attempts to use the psych unit as a place to hide from parole officers, to stay off the streets, or to avoid court dates. If we were not judicious with collecting collateral and carefully interviewing these patients, accepting them all at their word without question, we would not have enough beds for the severely mentally ill and actually suicidal.

 

[psychRA]

Do psychologists have years of training in inpatient and emergency psychiatry that would prepare them specifically for the sort of risk assessment required of a patient like this?

I definitely have the training and experience necessary to perform suicide risk assessments, and making decisions about whether suicide risk precautions are necessary is a routine part of my job. I don't believe that a psychiatrist is inherently more qualified than I am to do so.

Because I'm adequately trained in this area, I'm aware that our ability to predict individual behavior in this realm (as well as in the realm of predicting danger to others) is extremely limited. There is no such thing as a human lie detector. Even if there were, we know that the decision to attempt suicide is often an impulsive one; a patient who denies suicidality (and genuinely does not feel suicidal) when assessed at 9am may still be at risk for suicide minutes or hours later, depending on a multitude of factors. Even the most comprehensive assessment of suicide risk cannot predict suicide attempts with any degree of certainty. We make clinical decisions based on all of the information that is available, and we hope for the best.

 

[PsyDr]

This Buzzfeed investigative report is very thorough and fascinating, in a horrible kind of way. (The ability of Buzzfeed to publish great investigative reporting and also listicles made up of GIFs is an interesting dialectic)

“What The Fuck Just Happened?”

Lock them in. Bill their insurer. Kick them out. How scores of employees and patients say America’s largest psychiatric chain turns patients into profits.

www.buzzfeednews.com

How A 6-Year-Old Got Locked On A Psych Ward

His mother said the boy had merely thrown a tantrum. But a hospital owned by America’s largest psychiatric chain, UHS, held him for three days — and filed a court petition to keep him even longer. While in the hospital, the child suffered a bloody nose and was locked in a seclusion room in the...

www.buzzfeednews.com

Videos Show The Dark Side Of Shadow Mountain Youth Psych Facility

A psychiatric hospital and its director that are under state investigation. Riots that end with pepper spray. Staff who can’t begin to contain the violence. And patients as young as 5. Secret videos show the dark side of Shadow Mountain.

www.buzzfeednews.com

Videos Show UHS Hospital Staff Assaulting Young Patients

It was supposed to be a refuge for troubled adolescents and foster kids who had run out of other options. But at Hill Crest Behavioral Health — part of UHS, America's largest psychiatric hospital chain — a culture of violence flourished. Internal videos show staff members beating and dragging...

www.buzzfeednews.com

How a Giant Psychiatric Hospital Company Tried To Spin Us — And Silence Its Staff

A $100,000 crisis PR plan. An employee fired for supposedly speaking to a reporter. Another employee sued for allegedly leaking internal surveillance videos. Inside the war room of America’s largest psychiatric hospital chain as it responded to our two-year investigation.

www.buzzfeednews.com

You know buzzfeed was founded by the same people as breitbart and huffpo right?


It’s almost like the same group of people are selling polar opposite opinions to US consumers...

 

[Therapist4Chnge]

I conducted two years of suicide-related research back in the mid-00’s, and it was beyond frustrating to see how pervasive the “art” of assessing suicidality was at psychiatric hospitals and in-patient units. We know clinical judgement is a coin flip, yet it continues to be taught as this magical ability that can be handed down through observation and mentorship. I think some of it is training (or lack there of) in regard to being able to critically evaluating research findings, some of it is ego, and some is not being comfortable with the idea that we have so little control over our patients harming themselves.

A piece that has been overlooked in this discussion is the importance of the multi-disciplinary team and the difference between putting someone on watch/pre-cautions and an actual treatment plan via the treatment team.

Treatment plans need to be more than a progress note and/or documentation that the patient said they aren’t suicidal and that they agreed to not hurt themselves. We know from the research that “No Harm Contracts” do not make a treatment plan, yet they are still utilized in that fashion. Add in the mistaken belief by some to many clinicians that they are effective, it leads to a false sense of security.

So now we have a scenario where clinicians believe their clinical judgement is better than it is, some of which still use some sort of agreement as justification that the patient is less of a risk to not a current risk, while functioning within healthcare systems that are often overcrowded. Knowing all of this, i’m actually surprised there aren’t more adverse outcomes involving self-harm and suicide attempts.

I’d like to ask ppl’s experiences with multi-disciplinary teams in regard to managing a suicidal patient, as i’ve seen a wide range of pros/cons to having more cooks in the kitchen. Are they better than one evaluator? How about states that require two opinions?

 

[Mad Jack]

Agreed. In general, doctoral psychology programs differ immensely in training. Variability works both ways, some will be poorly trained and some will spend years researching and working with individuals at high-risk for suicide.


Some do. Not all.


I am sure this is setting-specific and people have different motivations depending on the setting. I've worked with individuals that lie the other way around (e.g., homeless folks in a Chicago winter that need shelter and inpatient units are much nicer that homeless shelters).

I would love to test the statement that most lie. I tend to not rely on individual experiences, which are far too biased.


I tend to question health decisions that are made on the basis of art more than science. Vice versa, I prefer entertainment that relies on art more than science.


Let us stay away from straw man arguments. We are talking about the ability to work with suicide and assess suicide risk.

I enjoy the psychiatry forum on SDN because there are many similar scientifically-minded posters. I wonder how many people would agree with you on the manner in which we figure out how to do suicide assessments, particularly for risk. It is likely that you are indeed a very effective clinician that can assess validity of suicide risk. However, do you trust every other psychiatrist - even those that had similar training to you - to figure out the art of assessment on their own? Or would you rather base this on some more objective empirical evidence?

I definitely have the training and experience necessary to perform suicide risk assessments, and making decisions about whether suicide risk precautions are necessary is a routine part of my job. I don't believe that a psychiatrist is inherently more qualified than I am to do so.

Because I'm adequately trained in this area, I'm aware that our ability to predict individual behavior in this realm (as well as in the realm of predicting danger to others) is extremely limited. There is no such thing as a human lie detector. Even if there were, we know that the decision to attempt suicide is often an impulsive one; a patient who denies suicidality (and genuinely does not feel suicidal) when assessed at 9am may still be at risk for suicide minutes or hours later, depending on a multitude of factors. Even the most comprehensive assessment of suicide risk cannot predict suicide attempts with any degree of certainty. We make clinical decisions based on all of the information that is available, and we hope for the best.

I agree with pretty much all of this. And I wasn't questioning whether psychologists were qualified enough, but rather just asking what kind of training you get because I don't know

 

[AbnormalPsych]

I agree with pretty much all of this. And I wasn't questioning whether psychologists were qualified enough, but rather just asking what kind of training you get because I don't know

I think the training is pretty varied, depending on the psychologists specific area of focus (e.g., populations, disorders, settings, etc) over the course of training. But in large I think it is integrated into our coursework and clinical training from year 1 and continually refined throughout our 5-8 years of practicum, internships, and postdoc training. Every supervisor I've worked with I have had trainings/discussions about suicide evals with in one on one supervision at the outset and onward as clinical situations dictated. In may state we even have required CEs on suicide assessment. When I worked in settings and with populations where SI was of higher prevalence, compared to my peers, I did notice I received much more one-on-one supervision and didactic based education (e.g., seminars, journal clubs) surrounding this literature and my performance. Some psychologists also conduct research in this area, and are in part trained through that avenue. In my graduate research I worked with populations with very high rates of SI and suicide assessments occurred regularly in my data collection activity.

What is psychiatrist training in this area like?

 

[LisaMC]

The original op ed is quite insightful and does argue for an important possibility.

 

[StellaB]

I’d like to ask ppl’s experiences with multi-disciplinary teams in regard to managing a suicidal patient, as i’ve seen a wide range of pros/cons to having more cooks in the kitchen. Are they better than one evaluator? How about states that require two opinions?

I'm not in a state that requires two opinions, but I do have experience working with multidisciplinary treatment team approaches with high suicide risk patients. Like any other type of team work, the quality varies greatly depending on the quality of the individuals on the team, and more importantly, on the team dynamic itself. When I have worked on teams that respect each discipline's unique strengths and present a unified front, patient care is significantly enhanced by the team approach. With regard to psychology and psychiatry relations - this means psychology staying in their lane (i.e. not making medication recommendations), and psychiatry staying in theirs (i.e. recognizing psychology's expertise in assessment). When each discipline tries to act like they are the be-all-end-all authority, is where you get too many cooks in the kitchen.

With regard to the Epstein situation, I would be curious what role, if any, institutional rules played. I've worked in correctional settings, and when short staffed there can be significant pressure to reduce/discontinue enhanced observation for suicide risk. This can take the form of comments from supervisors, onerous paperwork to continue observations past a certain timeframe, etc. This pressure shouldn't affect clinical decision making, but any psychologist worth their weight can tell you that of course it does.

 

[ellenew]

Do psychologists have years of training in inpatient and emergency psychiatry that would prepare them specifically for the sort of risk assessment required of a patient like this?

Most of my patients lie because they want to attempt again, learning to read which ones are and are not BSing you is an art more than a science and really requires structured training to develop a decent degree of skill with regard to.

Yes. Many psychologists do. Some specialize specifically in suicide risk assessment and prevention in postdoc/fellowship.

 

[AbnormalPsych]

I think the training is pretty varied, depending on the psychologists specific area of focus (e.g., populations, disorders, settings, etc) over the course of training. But in large I think it is integrated into our coursework and clinical training from year 1 and continually refined throughout our 5-8 years of practicum, internships, and postdoc training. Every supervisor I've worked with I have had trainings/discussions about suicide evals with in one on one supervision at the outset and onward as clinical situations dictated. In may state we even have required CEs on suicide assessment. When I worked in settings and with populations where SI was of higher prevalence, compared to my peers, I did notice I received much more one-on-one supervision and didactic based education (e.g., seminars, journal clubs) surrounding this literature and my performance. Some psychologists also conduct research in this area, and are in part trained through that avenue. In my graduate research I worked with populations with very high rates of SI and suicide assessments occurred regularly in my data collection activity.

What is psychiatrist training in this area like?

@Mad Jack would love to hear about psychiatry training in this area. I actually have no idea about what its like.

 

[Mad Jack]

@Mad Jack would love to hear about psychiatry training in this area. I actually have no idea about what its like.

In my program we get 2000 hours of ED/consult which is mostly geared around risk assessment with a bit of capacity/med management thrown in (depends on the patient mix you receive) at the busiest psych ED in the region, 600 hours of mobile crisis services, and a structured didactic curriculum in which we beat the topics to death basically. In addition to that we do on-unit and discharge risk assessments while we're doing our 3,000ish hours on the unit and take crisis call for the clinic every fourth night during all of third year. It's really variable though- the ACGME standards just state you have to have competence in suicide risk assessment and that you have "experience" in the emergency department, which is very ill-defined.

 

[WisNeuro]

In my program we get 2000 hours of ED/consult which is mostly geared around risk assessment with a bit of capacity/med management thrown in (depends on the patient mix you receive) at the busiest psych ED in the region, 600 hours of mobile crisis services, and a structured didactic curriculum in which we beat the topics to death basically. In addition to that we do on-unit and discharge risk assessments while we're doing our 3,000ish hours on the unit and take crisis call for the clinic every fourth night during all of third year. It's really variable though- the ACGME standards just state you have to have competence in suicide risk assessment and that you have "experience" in the emergency department, which is very ill-defined.

Sounds as variable as psychologist training standards. Almost everyone will have some cursory training and experience with risk/suicide assessment in their 7+ training years in clinical psychology. Those who work with specialized populations will get much more. For example, if you've done DBT work, or VA inpatient work, or something similar, you'll get pretty good at it. Other settings, not so much. As with most things, painting with a broad, ill-informed brush as the author in the article does, doesn't really help understand the situation.

 

[PikminOC]

Acgme is very strict and standardized. No pop up diploma mill MD schools

 

[BorderlineQueen]

Acgme is very strict and standardized. No pop up diploma mill MD schools

True but there are diploma mill DO schools. I know a lot of the DO students are complaining about all the new schools and the low quality.

 

[Mad Jack]

Acgme is very strict and standardized. No pop up diploma mill MD schools

They have gotten more lax in recent years as schools have established satellites and expanded classes. I'm shocked by the poor rotational quality of the local MD school, which only has 6 months of inpatient rotations during third year, far less than the 10 I got in my school of bone wizardry. The ACGME has similarly gotten more lax as they have attempted to address the primary care shortage, resulting in several new medicine programs that are almost entirely outpatient in their curriculum.

 

[PikminOC]

They have gotten more lax in recent years as schools have established satellites and expanded classes. I'm shocked by the poor rotational quality of the local MD school, which only has 6 months of inpatient rotations during third year, far less than the 10 I got in my school of bone wizardry. The ACGME has similarly gotten more lax as they have attempted to address the primary care shortage, resulting in several new medicine programs that are almost entirely outpatient in their curriculum.

There's still a bottlenck to become an MD, that's the number of residency slots

Med School Enrollment Expands, Concern for Residency Slots Lingers

Enrollment in US medical schools has grown by 31% since 2002, but averting a physician shortage hinges on boosting the number of residency training slots.

www.medscape.com

 

[PikminOC]

True but there are diploma mill DO schools. I know a lot of the DO students are complaining about all the new schools and the low quality.

Still the residency slots limit the number
Not like pop up psyd schools that are in business, and out of business.
There are online therapy schools too!

 

[PikminOC]

True but there are diploma mill DO schools. I know a lot of the DO students are complaining about all the new schools and the low quality.

And they got into do for a reason.
My quote was regarding MD specifically

 

[PikminOC]

They have gotten more lax in recent years as schools have established satellites and expanded classes. I'm shocked by the poor rotational quality of the local MD school, which only has 6 months of inpatient rotations during third year, far less than the 10 I got in my school of bone wizardry. The ACGME has similarly gotten more lax as they have attempted to address the primary care shortage, resulting in several new medicine programs that are almost entirely outpatient in their curriculum.

6 months of inpatient is still six months.
And they have to complete minimum of three years of residency.
The product of MD training is still quite rigorous

 

[Mad Jack]

True but there are diploma mill DO schools. I know a lot of the DO students are complaining about all the new schools and the low quality.

Many of the new MD schools are very similar to what you refer to as "diploma mill" DO schools. No teaching hospital, less and less inpatient, lackluster support from faculty and staff, etc. Guaranteed my older DO school would pass current ACGME standards, but they refuse to do so for political reasons despite our affiliated university having pushed for such a transition in the past. As was noted by another poster, residencies have kind of become the bottleneck though, so physician quality ends up more tied to resident quality than anything.

 

[AcronymAllergy]

In the psychology world, in years past, the same bottleneck role was served by internship. There have been efforts to standardize training at the graduate school level, but that's hamstrung by the relatively lax accreditation standards themselves. And psychology's background in academia, along with the sometimes widely-varied theoretical atmospheres of training programs, fosters greater variability.

But at the end of the day, all psychologists should have received training in suicide risk assessment. I don't know the proportion of psychologists who had inpatient MH unit placements during their training. My gut tells me that by the time folks finish internship, most have had it, but that's a guess.

 

[PikminOC]

Many of the new MD schools are very similar to what you refer to as "diploma mill" DO schools. No teaching hospital, less and less inpatient, lackluster support from faculty and staff, etc. Guaranteed my older DO school would pass current ACGME standards, but they refuse to do so for political reasons despite our affiliated university having pushed for such a transition in the past. As was noted by another poster, residencies have kind of become the bottleneck though, so physician quality ends up more tied to resident quality than anything.

It's good there is residency, yet another checkpoint. Minimum of three years.
This is very different from other fields.
Three rigorous board exams, numerous shelf exams, medicine is still the most standardized of all

 

[WisNeuro]

It is indeed different from other fields, three years of training in MH vs 7-8 in one in particular.