By far, one of the most enjoyable aspects of PBB has been that I have come into contact with a number of interesting and accomplished mental health professionals - whether they are clinicians, researchers, or both - that I might not otherwise have met. This has led to a number of fascinating and entertaining conversations and has exposed me to a wealth of research I had not previously seen. Yesterday, I had a timely email exchange with Captain Luther Dhillon-Davis of the United States Air Force during which he alerted me to an in press article he co-authored with Craig Bryan (author of the April 2009 Psychotherapy Brown Bag featured article) and Kieran Dhillon-Davis that touched upon a topic very similar to what we covered on the site yesterday. Capt. Dhillon-Davis made no request that I discuss the paper on PBB, but I thought the timing was too good to pass up on and the study was too interesting not to cover.
If you read yesterday's article, you will remember that Gould and colleagues (2005) found that, despite fears that assessing for suicide risk would increase suicidality in adolescents, the opposite occurred, with suicidal individuals experiencing significant decreases in distress and suicidal ideation after being asked questions about symptoms of suicidality. That, quite clearly, is important news, as it means that discussing and systematically assessing suicide risk causes no harm and can help provide information essential for effective interventions. In the article sent to me by Capt. Dhillon-Davis, the authors examined a similar phenomenon by testing the impact of the video-based Air Force Suicide Prevention Program (AFSPP). My intention in covering this article today is to expand upon yesterday's discussion and to apply it to another population, as I am particularly interested in studying suicidality in the military and helping to develop effective approaches to diminishing risk and believe that discussing the topic in forums like this can be a useful enterprise.
The utility of studies like the one conducted by Bryan, Dhillon-Davis, and Dhillon-Davis (in press) rests in their ability to empirically test our fears that discussing or being exposed to information about suicide can increase suicide risk. To be fair, in the past, there have been findings that indicate that such a connection could exist. In fact, Madelyn Gould, one of the authors of the study discussed yesterday, published a study in 2003 that found exposure to information on suicide warning signs could have iatrogenic effects. At the same time, such findings are far from universal and, in fact, represent a small minority of published research. For instance, Rudd and colleagues (2006) found that individuals exposed to a list of suicide warning signs experienced no more distress than did individuals exposed to a list of warning signs for a heart attack. Along those lines, we have to be careful not to become too attached to ideas that sound compelling or instill fear but lack a wealth of empirical support. Sometimes, the most compelling narrative does not match up with reality and sometimes the most interesting sounding theory proposed by the most intelligent person turns out to be wrong.
Suicide prevention efforts are not always limited to lists and discussions of risk factors as the case was in the Rudd et al (2006) study mentioned above. Some approaches use other forms of media in an effort to convey information. The example focused on in the Bryan, Dhillon-Davis, and Dillon-Davis (in press) article was the AFSPP, which relies heavily upon video footage as a teaching tool. The AFSPP was created more than 10 years ago in response to increasing rates of death by suicide among active duty personnel (Knox, Litts, Talcott, Feig, & Gaine, 2003) and it focuses on reducing malleable risk factors for suicide while bolstering protective factors. The program seeks to increase awareness regarding the nature of suicide risk, to create prevention programs, and to change policies in an effort to reduce the stigma attached to help seeking behaviors related to mental health difficulties. Prior research has demonstrated that the program has been highly efficacious in reducing suicide rates amongst active duty airmen (Knox et al., 2003). The AFSPP consists of 11 initiative and a description of the program is available for no cost at the following URL: http://afspp.afms.mil
In this study, the participants were 286 active duty USAF personnel who were participating in a two-week introductory class required for all Airmen assigned to their first duty station after graduating from technical training school. The sample was predominantly Caucasian and male. 11.2% of the sample was classified as currently suicidal based upon their scores on the Suicidal Behaviors Questionnaire - Revised. Amongst those classified as suicidal, a significantly higher number were female. Similarly, a significant number of participants who reported a history of past suicide attempts were female. Participants were assessed on their levels of positive and negative affect both prior to and following exposure to the suicide related video footage.
The participants' mean level of positive affect decreased following exposure to the films; however this effect was quite small. The participants' mean level of negative affect also decreased following exposure to the films and this effect was actually quite large. In other words, looking at the entire sample, following the films individuals tended to feel slightly less positive emotions and substantially less negative emotions than they did before viewing the films. Importantly, prior to the film, the sample reported a level of negative affect consistent with normative samples and an elevated level of positive affect relative to normative samples. Consequently, it is certainly possible that the minor decrease in positive emotions actually represents regression to the mean. Either way, this first finding did not indicate that there was any harmful impact on the overall sample as a result of viewing the films.
Still, the question remained whether suicidal individuals or individuals with a past history of suicide attempts might be impacted differently than individuals without such symptoms or histories. Fortunately, the authors compiled data capable of answering that very question. First, individuals with a past history of suicide attempts experienced no difference from individuals without such a history in their emotional responses to the films. Second, there was a nearly significant interaction (p = .051) of sex and suicidality, such that suicidal females experienced the greatest decrease in negative affect, followed by non-suicidal males and non-suicidal females. Suicidal males did not experience any change in negative affect in response to viewing the films.
So what do all of those findings in the previous paragraphs mean? First of all, whether an individual has a past history of suicide or not, viewing suicide-related films in the context of a suicide prevention program does not cause any harm. Obviously, the content of the film is an issue to consider, but these films emphasized educational material, not shocking or gruesome imagery. A small but significant decrease in positive emotions is to be expected in response to this type of program, but so is a substantial decrease in negative affect. Secondly, although males classified as currently suicidal experienced no change in their levels of negative emotions, suicidal females experienced a decrease in negative emotions and nobody experienced an increase in negative emotions. As such, there was absolutely no evidence supporting the idea that viewing these films caused any harm and, in fact, there was substantial evidence that the films actually had a positive effect above and beyond their goals of conveying information.
One important consideration raised by Brian, Dhillon-Davis, and Dhillon-Davis (in press) is the idea that there might be an age effect that impacts the effects of this type of suicide prevention program. Rudd et al (2006) proposed that, for adolescents, there could potentially be some danger and, given that the sample in this study was comprised of adults, that idea certainly can not be refuted by the data. As such, future research that investigates this phenomenon in adolescents would be of great value.
Ultimately, the take home point of studies like the ones discussed today and yesterday is that we need to openly discuss the phenomenon of suicide in order to help prevent it. Learning about suicide and being exposed to information regarding risk factors, whether on a paper list or through video format, does not appear to cause any harm and may, in fact, result in emotional benefits. Obviously suicide is an uncomfortable and emotionally charged topic, even if an individual has no experience with it and does not know anyone who does, but avoiding the topic out of fear of its potential impact is a disservice, particularly given the data we have indicating that at best it is helpful and at worst it is a harmless source of important information.
If you or anyone you know is experiencing thoughts of suicide, please immediately dial 1-800-273-TALK to reach the national suicide prevention lifeline. If you are not comfortable calling that number, please dial 911 or get somebody to take you to the emergency room.
If you would like to learn more about suicide or suicide prevention efforts, we recommend the following resources, all of which are available through our online store:
- Why People Die by Suicide
by Thomas Joiner
- Treating Suicidal Behavior: An Effective, Time-Limited Approach
by David Rudd, Thomas Joiner, and Hasan Rajab
- The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients
by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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