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Suicide/IAT

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by Grenth, Jul 2, 2018.

  1. Grenth

    Grenth Clinical Psychology PhD Student
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    I'm taking my APA-required social psych class right now and the professor has assigned some reading on how the implicit association test predicts suicide better than any current indicators such as a history of previous attempts (e.g., Nock et al., 2010). I looked more into the literature and saw that this effect has been robustly replicated by others. Given these results is there a reason is there a reason that the IAT isn't used more as a suicide risk assessment tool?
     
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  3. futurehopefully

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    Most of that research involves folks from the same lab.
     
  4. Ollie123

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    Agree that some wider replication would likely be good to see first. Perhaps more to the point though...everything I have seen on it has not really showed the level of sensitivity/specificity we would demand of a clinical measure. Especially in a fairly high stakes area like that. It's not face valid and this is certainly an area where there is more potential for legal/malpractice concerns.

    I'm short...it is promising and it could get there, but I don't think it's ready for primetime quite yet.
     
    #3 Ollie123, Jul 2, 2018
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  5. Justanothergrad

    Justanothergrad Counseling Psychologist
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    Do you want to sign off on someone not being a risk to themselves because of results on an IAT? or put them in a hospital based only an IAT? I don't. That screams liability problems without often replicated and highly validated sensitivity/specificity. Maybe one day, but to move to implicit measures and other similar approaches, I'd have to have some very strong evidence to feel safe.
     
  6. Grenth

    Grenth Clinical Psychology PhD Student
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    Thanks for the responses. I'll definitely keep digging into the literature and keep an eye out for updates in the future. My fledgling clinical scientist sense was that there were some aspects lacking research-wise and clinically I wouldn't feel comfortable using the IAT alone for risk assessment. The professor is a social psychologist though and doesn't see why we (clinicians) aren't using the IAT for everything. I think he's keen to see all of us clinical folks replaced by AI in the next few years.
     
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  7. Fan_of_Meehl

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    Fortunately, I think that mental health clinicians will be one of the LAST professions made obsolete by AI.
     
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  8. smalltownpsych

    Psychologist 2+ Year Member

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    Yup. The interpersonal matrix and how that affects and influences the complex interplay between behavior and emotions is where I make my money. The pure academics hate that our patients like us and that dynamic also helps the patients improve.
    :D
     
  9. Fan_of_Meehl

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    Right on. In psychotherapy, the therapist is assessor, diagnostician, bumbling mortal/human, keen (though flawed) instrument, test pilot, witch doctor, behavior analyst, the empathic other, and concert pianist (with oven mitts on)...all at the same time. What a field.
     
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  10. DynamicDidactic

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    did i miss something? Is there any evidence that the IAT can predict future suicide attempts or self harm? All the research is about past episodes. We have nothing useful in predicting future suicidal behavior.
     
  11. Ollie123

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    Far from perfect, but I know Nock (and possibly some others now?) have done at least a few prospective studies with the IAT now.

    As someone actively doing the work to replace us with AI (seriously - I have papers/grants in this area)...trust me, we are a lot more than a few years away.
     
  12. Grenth

    Grenth Clinical Psychology PhD Student
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    At least a couple I've seen look at prediction. Nock and colleagues (2010) "the implicit association of death/suicide with self was associated with an approximately 6-fold increase in the odds of making a suicide attempt in the next 6 months, exceeding the predictive validity of known risk factors (e.g., depression, suicide-attempt history) and both patients’ and clinicians’ predictions.". Additionally, Barnes and colleagues (2017) " d/sIAT scores significantly predicted suicide attempts during the 6- month follow-up above and beyond other known risk factors for suicidal behavior (OR = 1.89; 95% CI: 1.15–3.12; based on 1SD increase). The d/sIAT may augment the accuracy of suicide risk assessment."

    Many of the other studies were just looking at past episodes though and the validity of the predictive studies is certainly limited it seems.
     
  13. hamstergang

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    The problem I see is that while this may be better than anything we have, it's still not useful. It can push the odds of suicide attempt from very small to something slightly less small, and that's spread out over the next 6 months -- what are you supposed to do with that? To justify incorporating something into clinical practice, more specificity is needed.
     
  14. smalltownpsych

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    This captures so well much of what we deal with in the real world with so many aspects of treatment.
     
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  15. Fan_of_Meehl

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    Another problem that I see emerging in the era of 'zero suicide initiatives' is a complete lack of appreciation of the dangers/ disadvantages of overreacting to low-moderate levels of risk in ways that actually likely do more harm than good. For example, the ER doc who involuntarily hospitalizes a patient for admitting suicidal thoughts without intent/plan, access to means or preparatory behavior---maybe the patient called a crisis line and said he needed 'to talk' with someone and was told to immediately present to the ER and an overly cautious clinician involuntarily hospitalizes him, he loses his job, access to kids, etc. and is actually MORE at risk as a result. Or how about routinely sending cops ('wellness checks') to the homes of folks who no show for their appointments and don't return phone calls? This could easily serve as a disincentive for the patient to get involved in MH treatment in the future. Unfortunately, if you express any critical thoughts in relation to any particular 'save-the-world' initiatives/policies/procedures you risk immediate scorn and condemnation as someone who 'doesn't care about or take seriously enough' the problem of suicide. To the contrary, I actually care enough about it that I am willing to risk censure in order to try to promote adult conversations about how is it best to handle various scenarios without overreacting to the point of being counterproductive.
     
  16. AbnormalPsych

    AbnormalPsych Clinical Psychologist
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    YES. During my time in the VA this was one of the most frustrating (clinical) things I had to wrestle with.
     
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  17. temppsych123

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    I saw a talk by Marsha Linehan at a conference a few years ago, presenting data that suggested the effectiveness of DBT in decreasing suicidality among people with BPD is strongly related to decreases in hospitalizations associated with DBT. DBT does a good job (IMHO) at decreasing the costs associated with disclosing suicidality (normalizing assessment of SI, for example) and also avoiding the unintentional reinforcement of crisis behaviors through hospitalization.
     
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  18. Fan_of_Meehl

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    Unfortunately, it's only gotten worse...and keeps accelerating. One recent revision of local policy/procedure regarding MH no shows reads: " If three attempts to contact veteran are unsuccessful, contacting local law enforcement for assistance is recommended when risk of harm is deemed to be imminent. Consideration for contacting local law enforcement should be based upon the documented clinical determination of imminent risk." So, after three attempts to contact (on three separate days, sometimes separated by several days such that we may be talking a time frame of, say, 2-3 weeks since the last appointment) and on the basis of NO current/recent data or observations, a clinician is supposed to somehow 'determine' (based on WHAT, exactly?) whether the veteran IS or IS NOT currently 'at imminent risk.' How in the hell do you do that without being able to speak with them or without receiving additional information (say, from family members). Bear in mind that the policy explicitly applies to veterans at ANY level (low, med, or high) of chronic suicidal risk. The typical situation will be one in which they routinely missed their last appointment and simply have failed to respond to follow up attempts by phone to reschedule (happens ALL THE TIME in outpatient mental health and--absent any additional significant and compelling info--does not in any way, shape, or form allow one to conclude that the veteran is 'at imminent risk"). Striclty speaking, only recent/current data or observations could possibly be used to 'determine (strong language) that the veteran is at imminent risk." But, of course, the policy squarely and firmly places the responsibility for 'determining imminent risk' on the shoulders of the clinician (but without specifying an actual means of doing so in that circumstance). I'm thinking of reviewing/summarizing (from the professional literature and case law) the most typical examples of data/observation that professionals rely upon to 'determine imminent risk' (of self/other harm) so that I can enumerate them (in the required progress note) and note as well how I do not observe that the veteran is exhibiting (or has recently exhibited) any of these signs. Not sure what else to do.
     
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  19. DC_Psych

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    Not sure if you specifically meant to call out Zero Suicide initiatives or if your wording was just a coincidence, but Zero Suicide as a whole is definitely not a proponent of more hospitalization. On the contrary, they advocate least restrictive, evidence based care with hospitalization as a last resort for only the most high risk patients. Having trouble posting a link here, but google 'zero suicide least restrictive care.'
     
    #18 DC_Psych, Jul 5, 2018
    Last edited: Jul 5, 2018
  20. Fan_of_Meehl

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    And if hospital bureaucrats and administrators actually interpreted 'zero suicide' to mean 'we will implement least restrictive, evidence based care with hospitalization as a last resort only for the most high risk patients,' then, obviously, I wouldn't have a problem with that as it's exactly the approach that I believe in and act out in everyday clinical practice. The issue, as I see it, is that using language like 'zero suicide' tends to (especially in the minds of the non-clinical types) instill the expectation that we are 100% knowledgeable about, 100% in control of, and therefore 100% responsible for all of the variance associated with suicidal ideation, behavior, and completion. An ounce of familiarity with the literature or a week in clinical practice would disabuse anyone of such notions. Why are there not 'zero heart attack' or 'zero seizure' initiatives in cardiology or neurology? It's also reminiscent of the phrase 'zero tolerance' as if to imply that the emergence of suicidal ideation/behavior represents some sort of crime, misbehavior, or shameful breach to be avoided at ALL costs.
     
    #19 Fan_of_Meehl, Jul 6, 2018
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  21. DC_Psych

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    I think that's a fair point about the language. The purpose is intended to be aspirational, but it's frustrating that some might interpret the language literally, without taking to heart the point of these initiatives, which are to use practices that will get us closer to zero suicides, not further away. What would you suggest as alternative language?
     
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  22. Fan_of_Meehl

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    Good question. Personally, I would suggest avoiding language that is unrealistic or utopian. Frankly, I think it's even a bit megalomaniacal for someone (or some institution) to say something like, 'Our goal is to eliminate suicide, and, my fellow countrymen, we CAN, and we WILL eliminate it!" I don't understand the need for slogans such as 'zero suicide.' How about just focusing on identifying and disseminating good evidence-based practices such as suicide safety planning, collaborative individualized case formulation, and a mature realization that not 100% of control of the outcome of suicide rests with the clinician?
     
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  23. smalltownpsych

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    Along the lines of this discussion, one of my patients who had a very close family member commit suicide was extremely upset about a suicide risk program at school that had the slogan of suicide being 100% preventable. Here is an article describing that phenomena and the problems associated with it. Interestingly, the kid referred to in the article could have been my patient. Is Suicide 100 % Preventable? Probably not ...
     
  24. smalltownpsych

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  25. Fan_of_Meehl

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    And I think that, if we've learned anything in psychology, we've learned that attempts to exert tyrannical control over the behavior and thoughts of others (even for a 'good' or well-meaning purpose) tend not only to be ineffective, but to often backfire and bring about a result opposite to the stated purpose of the tyrannical policies.
     
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  26. DC_Psych

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    I get how this can be upsetting for survivors to hear, but I don't think the point is to blame them or suggest that they didn't do enough to prevent the suicide. I think there's an important dialectic here. We don't want survivors to blame themselves, but we DO want people to be proactive in preventing suicide by checking in with friends, asking about suicide, reducing access to lethal means, etc., all of which can and do prevent suicides. "There's nothing I could have done" may be helpful for survivors, but "There's nothing I can do" is a dangerous message from a public health perspective.
     
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  27. Fan_of_Meehl

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    Very much agreed. 'dialectic' is the perfect term/concept here and it illustrates the complex and nuanced nature of the issue. Neither extreme (we can do everything vs. we can do nothing) is accurate or helpful.
     
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  28. smalltownpsych

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    Agreed and "there is nothing that you could have done" would not likely be a message I would try to give to a survivor, but my own patient clearly felt that the opposite message was a blaming one to him and reacted very strongly to it. As far as public health policy goes, I'm a bit cynical these days about that and am leaving that world to go to the exclusive private pay route. I think that we are so far from where we need to be as a culture regarding public health that the whole system is damaging and that at this point I need to be outside of it to be able to do the most good for myself as well as my patients.

    *edit to add* On re-reading this it might overstate my true perspective, but I am having a bit of short-timer syndrome. :D
     
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  29. temppsych123

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    I wholeheartedly agree, and didn't fully understand this conflict until I sat in on a survivors of suicide loss support group - there is SO much guilt, shame, "if only" thinking following loss of a loved one to suicide, it can be quite easy to see suicide prevention focused materials as blaming, even if that's not the intention at all.
     
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  30. cara susanna

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    Another issue that I have with "zero suicide" initiative as it is being implemented bureaucratically is that, from my experience, it's more about checking off boxes than the actual quality of care. In fact, I've seen the quality of care suffer as a result. As as has been mentioned, many of the policies that I've seen are actually more likely to reinforce suicidal behavior, and we have research that forced hospitalizations do not help suicidality. Not to mention that many of these policies impact the availability of effective services like DBT (for instance, I've seen full model DBT programs get closed because the wait list was too long since the treatment lasts one year).

    I also wish that people would differentiate between chronic and acute risk. That seems to be a pretty big issue here--a provider is worried about a patient, so they request a high risk flag even though 1. the flag doesn't functionally change the patient's care at this time (they're already being seen weekly, followed by suicide prevention, etc) 2. the patient appears to have high chronic, but not imminent, risk.

    I saw someone once post in a Psychiatry forum questioning how MH providers allowed themselves to become the gatekeepers of suicidal behavior, and I thought that was a fair point. Of course, there are things that we can do to reduce risk and help people find other ways of coping, and in the end it's still up to them (talk about a dialectic).
     
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  31. Fan_of_Meehl

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    It very much gets at issues at the core of dealing with 'assimilated stuck points,' say, within a Cognitive Processing Therapy approach to treating PTSD. People need to be able to acknowledge and adopt reasonable levels of responsibility for their action/inaction rather than judging themselves by some unrealistic or perfectionistic standard. Therapists working with suicidal clients have clear ethical obligations to practice with prudence, compassion, competence and within the bounds of professional standards of care and practice. We don't have any obligation to 'rid the world of the scourge of suicide.' Such a goal would be unrealistic and narcissistic in the extreme.
     
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  32. StellaB

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    I totally agree. And I will add the probably controversial view that a zero-tolerance style intervention could be very insulting to individuals who are thinking about suicide (I'm not referring here to individuals in acute and transient crisis, rather chronic pain / terminal illness / severe long-term debilitating depression, etc.). Obviously we would never push clients in that direction, but individuals who are realistically considering suicide may be a lot less willing to seek counseling in the first place if they feel like their autonomy to make that choice wouldn't be respected. It's way too complex and serious of an issue to take a black and white approach to.
     
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  33. foreverbull

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    A few colleagues work with some older folks in skilled care facilities who are cognitively declining with dementia, and are aware of it, many completely bedridden, no quality of life, and wish they could die, yet they aren't allowed to choose when they die and they are pumped full of meds to the point of almost complete sedation. It happens more often than most folks realize, and some folks live for several years this way. As a society, apparently we prefer that folks are miserable, declining, hoping for death, but still breathing during the twilight years rather than allow them to choose when they can die with dignity when they have terminal illnesses and/or dementias.

    Just another wrench to throw into this very complex and heated topic....
     
  34. DC_Psych

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    Do you have data to back up the claim that Zero Suicide has reduced quality of care? On the contrary, evidence suggests that it is improving quality of care for organizations that have implemented a Zero Suicide framework (e.g. Henry Ford Center).

    Hogan, M.F. & Goldstein, J. (2016). Suicide prevention: An emerging priority for health care. Health Affairs, 35, 1084-1090.
     
  35. cara susanna

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    No data, personal observation, and I'm not saying that this is what the Zero Suicide framework is meant to look like. See Fan of Meehl's above description in post #19.

    Also, just speaking from my opinion, I really wish they'd given the initiative another name.
     
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  36. Fan_of_Meehl

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    Here's just one small way though, admittedly, anecdotal: by procedurally *mandating* specific series of long forms, checklists, or symptom self-reports for every encounter, you necessarily reduce the amount of time the clinician has to utilize in session to work on an actual problem (and make progress) that may actually be contributing to hopelessness/ suicidality. For a patient who just got divorced and is dealing with some hopelessness (but who does not meet involuntary admission criteria), which would be the more clinically prudent way of spending the remaining 45 min of the session (and who should decide?): (a) completing 'Mandated VA Forms/Questionnaires A through F' for 30 mins, leaving only 15 min for Socratic questioning, guided discovery, and cognitive restructuring to combat acute hopelessness, or (b) going light on the VA mandated stuff (maybe spend 10 mins on it), leaving a good 35 mins to conduct some productive cognitive therapy to address the main likely driver of hopelessness and suicidal risk between now and next session? VA administrator types would insist on (a) but I would argue that most good clinicians would choose (b). A crappy but brownnosing clinician would happily do (a) and receive a 'gold-star' from the local Church of Suicide Prevention since the appropriate mandated religious rituals to make everyone 'look good' were piously observed by Brother Brown-noser.

    Edit: this comment more addresses the hamfisted and ideologically-driven implementation of one interpretation (that of a large Federal bureaucracy) of 'zero suicide' and (ostensibly) suicide prevention initiatives. They may be doing some magnificent, flexible, and effective implementations at that Ford center and elsewhere.
     
    #35 Fan_of_Meehl, Jul 6, 2018
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  37. DC_Psych

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    Thank you both for clarifying. Out of curiosity, are they using the term "zero suicide" at VA's to describe some of the non-evidence based /iatrogenic practices you've described on this thread? If so, that's really annoying. It seems like the term "zero suicide" has somehow been conflated to include all sorts of procedures that are contrary to the Zero Suicide model. And while I think that taking issue with the language "Zero Suicide" is valid, the positive results of the movement can't be denied. While language is important, I do wonder if focusing too much on the flaws of slogans such as "Zero Suicide" and "Suicide is 100% Preventable" is a distraction from the actual content of these initiatives (i.e. Don't cut off your nose to spite your face :) .
     
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  38. cara susanna

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    Yeah, I think it's the language combined with the specific way it's been implemented here. And, I'm not exactly sure which initiatives are "zero suicide" and which are just our regular suicide prevention. I do want to clarify that some of the suicide prevention policies and practices here are really great and seem to align with what's mentioned in that article you linked. I just think that there's this intense terror of suicide (administratively, more than anything) that can result in higher-level decisions that may actually impede our clinical work.

    FWIW, I was in a state that had a zero drunk driver goal and I didn't like that phrasing, either. I'm all about achievable goals. That being said, I get that it's aspirational and maybe some of my hang-ups about it aren't 100% reasonable. :)
     
  39. Fan_of_Meehl

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    The VA does have some reasonable policies/ practices when it comes to suicide prevention including written suicide safety planning and some of the mandated follow up (e.g., after an inpatient stay) guidelines. However, at the level of local implementation, the mission of suicide prevention is generally carried out in an extremely authoritarian, overly-concrete, blaming/shaming, scapegoating, and arbitrary manner by clinically unsophisticated bureaucrats and the apparent (though unstated) goal is the utter eradication of individual clinical decisionmaking. Your mileage may vary, depending on your VA site.
     
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  40. cara susanna

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    Yup, this exactly. Also, at the VAs I've been at, actual clinical care has been impacted by a focus on access (getting as many people in as quickly as possible) to the extent that we have difficulty seeing people weekly for EBPs. Access is a big part of the VA's suicide prevention attempt--which I agree with in principle, but access isn't really that helpful if you aren't getting people the actual treatments that they need. Honestly, sometimes I get the impression that all they care about is that we saw the patient and assessed that they aren't high risk, even if we don't implement any actual clinical intervention.
     
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  41. Fan_of_Meehl

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    This is what happens when your organization takes a bureaucratic-industrial assembly-line and public-relations approach to healthcare smiling ear-to-ear with profane incompetence. But, the bright spot is that I had some really cool clinical encounters today with folks who were really putting some things together in their lives, recognizing--for example--that their anger in many different situations was an understandable consequence of their distorted views of the situations based on prior experiences. That kind of progress pays dividends geometrically into the future to, hopefully, make their lives better. Not a bad job.
     
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  42. DynamicDidactic

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    Coyle et al., 2018
    On the potential for iatrogenic effects of psychiatric crisis services: The example of dialectical behavior therapy for adult women with borderline... - PubMed - NCBI
     
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  43. temppsych123

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