Taking the Teacher out of the Feedback: Connecting with Patients at Risk of Suicide

• Matison Alderman

• Laura Ayala

• Simran Sandhu MD

• Adriana Foster MD

What do we know about clinicians’ behavior in interactions with patients who are suicidal?

FACTS ABOUT SUICIDE:WHO & CDC DATA

10th highest cause of death in US.

2nd leading cause in ages 10 to 34, and 4th leading cause ages of 35 to 54 1.

From 1999 to 2016, the suicide rate increased 28%.

Of people who die by suicide, 38% visit a healthcare provider within a week, 64% within a month, and 95% within a year before the attempt.

Of people with mental health or substance abuse diagnoses who attempt suicide, 25% visit a healthcare provider within a week, 44% within a month, and 73% within a year.

(Wang, 2016)j

Negatively Phrased Questions

• Many clinicians ask negatively phrased questions such as ,”You are not having thoughts of harming yourself?” (75%)

• Negatively phrased questions are more likely to elicit negative responses, missing critical opportunities to assess suicidality.

(McCabe, 2017)

Clinicians show distinct emotional responses to patients who attempt suicide.

• It is hard to get feedback from patients who are suicidal.

• Clinicians show distinct emotional responses to patients who attempt suicide.

• Negative emotional reaction to a suicidal patients correlate with outcomes.

• Clinicians treating suicidal patients are more overwhelmed, distressed, and avoidant of them

(Galynker, 2013)

Suicide Risk Assessment

• Can’t teach at the clinical point of care -- stakes are too high

• Current teaching tools: SPs, Role-Play, Videos, Lectures, Case Scenarios and Panel Discussions, Questionnaires

• Feedback: From SPs (via checklists), lecturers, panel members, questionnaire results

Virtual Humans and Artificial Intelligence

• Up-front costs

• Portable, easy to disseminate, allow repetitive practice

• Immediate feedback on multiple variables

• Tracks multiple aspects of interaction (voice and facial expression analysis)

• No risk to human patients or SPs

• Full transcript of interaction (including suicide risk assessment)

• Data shows that Virtual Humans can be used to teach empathy.

(Foster, 2016)

The Patient: Bernie Cohen

3D Virtual Human

Speaks, can be spoken to,

gives feedback using AI

Virtual People Factory,

University of Florida,

Computer and Information

Science and Engineering

Department

The Patient: Cynthia

Young

3D Virtual Human

Speaks, can be spoken to,

gives feedback using AI

Virtual People Factory,

University of Florida,

Computer and Information

Science and Engineering

Department

The Feedback• Transcript with descriptive suicide risk assessment

• Self-rated Emotional Self Awareness - Therapist Response Questionnaire- Suicide Form, (TRQ-SF)

• Empathic communication feedback - Empathic Communication Coding System (ECCS), with alternative responses

• Non-verbal emotional response facial expressions - NOLDUS°

(Barzilay, 2018), (Bylund and Makoul, 2002)

Therapist Response Questionnaire, Suicide Form

• Rate how much each of the following is true regarding how you felt with/about this patient:

• 0(“not at all”) 1 (“a little”) 2(“somewhat”) 3(“quite a bit”) 4(“extremely”)

• S/he made me feel good about myself.

• I liked him/her very much.

• I felt like my hands were tied or that I was put in an impossible bind.

• I felt dismissed or devalued.

• I felt guilty about my feelings toward him/her.

• I thought life really might not be worth living for him/her.

• This patient gave me chills.

• I had to force myself to connect with him/her.

• I feel confident in my ability to help him/her.

• We trust one another.

(Barzilay et al, 2018)

“Below you will find feedback on your

emotional reaction to the virtual human

interaction based on your TRQ-SF scores”Hopelessness score =

Emotional Detachment score =

Distress score/Overall negative emotions score* =

Please assess your emotional reaction in the interaction with the virtual human based on the score ranges for each domain

shown below:

Hopelessness and emotional detachment score:

0-1= minimally hopeless/detached.

1-2= fairly hopeless/detached.

2-4= highly hopeless/detached.

Distress and overall negative emotions score:

0-1=minimal distress/ overall negative emotions.

1-2= fair distress/negative emotions Fair does not seem the right word here, pls revise

2-3= high distress/overall negative emotions.

Engaging with acutely suicidal individuals at imminent risk is stressful to all clinicians. Such interactions often cause negative

emotions such as anxiety, fear, hopelessness, emotional detachment and distress. We encourage you to try to be aware of your

emotions. Self-awareness of these emotions may help you with the suicide risk assessment and to maintain empathic alliance

with the patient.

Empathic Communication Coding System(ECCS)

• Empathy - major role in the therapeutic alliance

• Participants rating clinicians high in empathy - 80% lower odds of reporting errors

• Higher levels of empathy - better clinical outcomes for their patients ECCS - Method for identifying patient-created empathicopportunities

• 0-6 scale measure rating a clinician’s empathic response (0=Denial of the patient’s perspective to 6=Shared feeling or experience)

(Bylund and Makoul, 2002), (Foster, 2019), (Hojat, 2011)

Empathic Communication Feedback with ECCS

Bernie: It feels like a piece of my soul was ripped out, all that is left is a bleeding

wound.

Student: I once lost someone very special to me. I understand the pain that you are

feeling (Shared feeling=level 6)

Bernie: It feels like a piece of my soul was ripped out, all that is left is a bleeding

wound.

Student: That sounds so painful. Are you in pain? (Acknowledgment with

pursuit=level 4)

Bernie: I don’t know if I’m anxious, I feel horrible, like my soul is bleeding. Like a piece

of me has been ripped out.

Student: That sounds tough. (Acknowledgment=level 3)

Bernie: It feels like a piece of my soul was ripped out, all that is left is a bleeding

wound.

Student: Have you spoken to anyone else? (Implicit recognition=level 2)

(Bylund and Makoul, 2002)

What’s next?

• Record and create feedback on non-verbal communication: facial affective reaction based on data from NOLDUS face reader

• Assessment of patients’ suicide outcomes

Collaborators

• Igor Galynker MD, PhD, Shira Barzilay, PhD

Icahn School of Medicine at Mt Sinai

• Benjamin Lok, PhD, Heng Yao

University of Florida, Computer Information Science and Engineering

• Erica Musser, PhD

FIU Department of Psychology

• Aniuska Luna, PhD

FIU Department of Psychiatry and Behavioral Health

References:

• Wang Y, Bhaskaran J, Sareen J, Bolton SL, Chateau D, Bolton JM. Clinician prediction

of future suicide attempts: a longitudinal study. The Canadian Journal of Psychiatry. 2016

Jul;61(7):428-32.

• Yaseen, Z. S et al (2013). Distinctive emotional responses of clinicians to suicide-

attempting patients-a comparative study. BMC psychiatry, 13(1), 230.

• McCabe R, Sterno I, Priebe S, Barnes R, Byng R. How do healthcare professionals

interview patients to assess suicide risk?. BMC psychiatry. 2017 Dec;17(1):122.

• Barzilay, S., et al. (2018). Emotional responses to suicidal Patients: Factor structure,

construct, and Predictive Validity of the Therapist response Questionnaire

• Bylund CL, Makoul G. Empathic communication and gender in the physician–patient

encounter. Patient education and counseling. 2002 Dec 1;48(3):207-16.

• Foster A, Chaudhary N, Kim T, Waller JL, Wong J, Borish M, Cordar A, Lok B, Buckley

PF. Using virtual patients to teach empathy: a randomized controlled study to enhance

medical students’ empathic communication. Simulation in Healthcare. 2016 Jun

1;11(3):181-9.

• Hannan J, Sanchez G, Musser ED, Ward-Petersen M, Azutillo E, Goldin D, Lara EG,

Luna AM, Galynker I, Foster A. Role of empathy in the perception of medical errors in

patient encounters: a preliminary study. BMC research notes. 2019 Dec;12(1):327.

• Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians'

empathy and clinical outcomes for diabetic patients. Academic Medicine. 2011 Mar

1;86(3):359-64.