Hi Feeling Good friends and colleagues,
I just received the following email from a therapist who was shocked to discover that her patient was suicidal after reviewing his scores on the Brief Mood Survey. Her intervention likely saved his life.
Patient suicides are not uncommon, sadly, and represent the dark side of our profession. The death of any patient is an enormous tragedy for the patient, obviously, and is devastating for the family and friends as well. Patient suicides can be incredibly demoralizing and anxiety-provoking for the therapist, too. It is imperative, in my opinion, that therapists have the best, state-of-the-art tools for detecting the emergence of suicidal urges so that we can intervene and have the greatest chance of preventing these horrible events.
In two upcoming Feeling Good Podcasts, Fabrice and I will discuss what happened to a psychologist named Harold who thought he did not need to use the Brief Mood Survey to track his patients’ symptoms at the start and end of every therapy session. Like so many therapists, Harold was convinced that he was sensitive and empathic and really understood how his patients felt with reasonable accuracy. When his favorite patient unexpectedly committed suicide following a particularly “good” therapy session, Harold was understandable devastated. He felt intensely depressed, anxious, ashamed, inadequate, alone, hopeless, and angry. You may find these two podcasts interesting and sobering.
My research and training experience indicate that therapists’ perceptions of how their patients feel (in terms of suicidal urges as well as severity of depression , anxiety and anger) are often way off-base, but therapists don’t realize this because most of them are not assessing assessment scales to track progress at every session. In addition, therapists’ perceptions of how empathic and helpful they are also way off-base much of the time for the same reason. They don’t measure empathy, and most don’t even ask patients to rate how warm and understanding they are.
That’s why I developed tools like the Brief Mood Survey, so therapists can track patient progress in multiple dimensions before and after every therapy session. I believe it’s use represents a major breakthrough in psychotherapy, because it’s like having an emotional X-ray machine to inform the therapist about what’s really going on, and to guide the treatment. Of course, I’m more than a little biased on this point! And the use of the BMS requires lots of courage, because the vast majority of patients are shockingly honest in the way they rate their therapists on these scales, and while the information can be invaluable, and even life-saving, it can also be quite disturbing and threatening to the therapist’s ego.
I just wanted to let you know that I recently started using the THERAPIST’S TOOLKIT and found myself in a similar situation you described. I recently had a patient whose scores were virtually ZERO on the Brief Mood Survey one week (meaning no symptoms at all), so I was convinced he was doing well. However, the following week I was alerted to high scores on your two-question “suicidal impulses” scale, which, to my chagrin, I nearly missed. That’s because I am in a new office with low lighting and I am visually impaired. But when I looked more closely, I discovered there my patient not only had suicidal thoughts and urges, but an actual plan for suicide!!!
Boy was I grateful having on hand the full blown Suicidal Urges Survey and Suicide Assessment Interview, which I proceeded to do in a two-hour session the following day. Just as surprising, his scores following THAT session were all ZERO again (except for Empathy and Self Help:-)
(David’s explanation. Scores of zero on the Depression, Suicide, Anxiety and Anger Scales are the best possible scores, indicating no symptoms at all. In contrast, scores of 20 out of 20 on the end-of-session Empathy and Helpfulness Scales are the best possible scores, indicating that the therapist was tremendous empathic and helpful during the session.)
Although I was/am at least temporarily relieved by the rapid reversal, I can’t say I know how to account for it, since most of the interview was assessment based, unless I just ooze TEAM-CBT without realizing it!
All that came to mind was “Hawthorne Effect.” As an aside, I know the “Suicidal Urges” survey is one of the “experimental” ones, but I saw no scoring sheet; I imagine they generally correspond with the BMS, the higher the worse.
Also, in answer to your query, I for one would LOVE to learn more about the Self-Defeating Beliefs survey and/or any info you impart in this regard. I was focused on that with the patient when I almost missed his staggering scores on the two questions on suicidal impulses. But I would like to return to it, and I will plan to give it for homework on a weekly basis to check his “emotional temperature” which is vitally important for this patient as you can imagine, I will consult some colleagues as well who have expertise in ethics and legal issues.
My TEAM CBT group (with Lynne Spevack) meets tomorrow, and we will focus on Testing, yay! And on Monday I will be starting Taylor Chesney’s TEAM CBT group! Both groups meet 2x/month. If only there were a group that met every day:-)
Meanwhile, I hope you’ve received my check by now for the EASY Diagnostic System which I cannot wait to get my hands on and need it desperately!!! When might I expect to receive the email with this valuable info?
I am enjoying your Feeling Good Podcasts, as well as your Feeling Good Blog and newsletter. I am more than fairly certain, were it not for your inventory (the Brief Mood Survey), I would have missed this potentially life-saving intervention. I’d even done a brand new Intake the week before. Although we do not have the power 100% to prevent a person from committing suicide, if we do not detect it we don’t have a fighting chance. I at least have the peace of mind now that with this knowledge, I can do everything in my power to insure this patient gets all the help he needs and hopefully the right help.
Thank you for being you and your contributions for making such a meaningful difference in the world for our patients and us therapists!
PS I also really appreciated your podcast on anti-depressants, which I LOVED and wasn’t surprised. I’m sure that took tremendous courage, along with your well-intact integrity to speak your truth. I wish more Psychiatrists were like minded. Until there is such a paradigm shift, which I think is coming, such decisions will have to be decided between the patient and their doc largely comprised of big Pharma mentality. who’ve drunk the cool aid, sadly.
Thank you for your enlightening email. I greatly enjoyed reading it, and kudos to you for saving your patient’s life.
You asked about the scoring of the two-item Suicidal Urges scale. I intentionally don’t have a strict numerical scoring key, as I want the therapist to attend to it thoughtfully. There are some guidelines in the massive update to the Therapist’s Toolkit. You probably have it already, but email me if you need it.
The first of the two screening items asks about suicidal thoughts and fantasies. Most depressed individuals will have these thoughts, such as the idea that they might be better off dead, but this is not generally alarming if there are no suicidal urges. Of course, you will always want to back up the survey with some questions to make sure.
The second of the two screening items asks about suicidal urges or plans. Any endorsement of this item is more worrisome, and usually merits a suicide assessment interview, just as you did. In general, you will only have to do this once with any particular patient, and it should ideally be done at the beginning of therapy, at the initial evaluation.
A third thing is to note changes in how the patient answers these two items, since any increase in the scores can indicate the development of increased suicidal urges. And as you say, we cannot 100% prevent suicide attempts in our patients, but the Brief Mood Survey will give you vastly improved information, since you will have the patient’s scores at the start and end of every therapy session.
One additional point, most versions of the Brief Mood Survey ask how the patient is feeling right now, just prior to the start of the session, and once again right after the end of the session. This is so the therapist can find out how effective, or ineffective, the session was. Such information is incredibly valuable! However, you can also ask if the scores reflect how the patient was feeling during the week, between the sessions. This is important, because the patient may have had times when he or she was feeling more suicidal, and this might merit a more intensive interview to assess the risk.
When you receive you EASY Diagnostic System from me (I assume you’ve already don this), you’ll find a structured screening interview for suicidal patients at the end of the diagnostic manual. This can be very helpful. There’s also a chapter in my psychotherapy eBook (Tools, Not Schools, of Therapy) on “The Prediction and Prevention of Suicide and Violence” that can be helpful as well. I have also included that chapter in the upgrade to the Therapist’s Toolkit.
Finally, please give Lynne Spevack my regards. She is a terrific teacher and therapist! I enjoyed catching up with her at the Newark workshop and encouraged her to meet more frequently with her training group. I agree that twice a month is not really enough. Keep in mind we now have three TEAM-CBT training centers in New York (for links, check out my referral page), plus numerous weekly online training groups that therapists around the world can join.
All the best,