The Clinical Angle - Lewis
Getting suicide out in the open (setting): Implementing an ecological momentary assessment study at the Austen Riggs Center.
Katie C. Lewis
Austen Riggs Center
Ecological momentary assessment (EMA) is a valuable yet under-utilized methodology in the field of suicide research. While EMA studies have been conducted in inpatient, outpatient and community samples, use of EMA methods to study suicidal thoughts and behaviors in residential treatment settings has been limited. Studying daily fluctuations in the suicidal thoughts of patients enrolled in residential treatment may yield unique and valuable information, as these patients often present with complex clinical challenges and are also available to participate in research for longer durations than those who are receiving acute care in a more time-limited setting.
The Austen Riggs Center, where I am employed as a research psychologist, is a small residential psychiatric treatment facility that specializes in the treatment of adults diagnosed with complex psychiatric disorders. Over half of Riggs patients report a history of at least one prior suicide attempt upon admission, and persistent suicidal ideation is a frequent clinical concern. In contrast to other residential or inpatient treatment programs, Riggs features an “open setting” in which there are no locked doors, and patients are free to leave the campus and take excursions into downtown Stockbridge or other surrounding Berkshire County towns. The setting provides a unique background both for clinical treatment and for conducting psychological research. While patients spend most of their day meeting with treatment providers or interacting with peers in the therapeutic community, they may also spend an afternoon creating art at the hospital’s Lavender Door gallery, go out to see a movie, or head home for the weekend to visit family and friends. The range of social interactions that patients at Riggs potentially have while in residence (both from a research and particularly from an EMA perspective) provides a unique opportunity not only to develop an understanding of how they negotiate interpersonal conflicts and closeness with their therapists, but also how interpersonal patterns may translate across peer, friend, and family contexts.
My primary current research project at Riggs is an EMA study focusing on the relationship between personality organization, interpersonal events, and the emergence of suicidal thoughts and impulses in patients diagnosed with severe and persistent psychopathology. Participants in my study complete baseline personality and interpersonal measures (including circumplex measures such as the IIP-SC (Hopwood, Pincus, DeMoor, & Koonce, 2008), CSIV-32 (Locke, Craig, Baik, & Gohil, 2012) and ISC (Hopwood et al., 2011) and provide information about their suicide attempt and psychiatric treatment history. After this initial assessment, participants use their smartphones to describe their experiences in interpersonal relationships over the following two week period. They additionally report on changes in mood and self-destructive urges, creating an opportunity for us to track how particular interpersonal situations and perceptions of self and other may be related to the emergence of self-destructive thoughts and behaviors in real time. The aim of this study is to increase understanding of how interpersonal ruptures influence suicidal ideation, and to consider how this knowledge may be used to inform clinical treatment with suicidal individuals.
Conducting research at Riggs presents a range of interesting opportunities and challenges. As previously noted, the use of EMA methods to study suicide in residential settings is relatively new. While Riggs has served as the setting for a number of longitudinal studies in the past, such as the Follow-Along Study (Perry et al., 2009), the concept of using intensive daily repeated measures to understand interpersonal and clinical functioning was relatively new. Clinical staff at Riggs initially expressed a range of concerns about how the project would influence daily clinical operations, including:
- Concerns that the daily EMA rating process may interfere with patients’ interpersonal engagement – for example, would patients be reticent to interact with other people in the community, knowing that they were being asked to rate these interactions?;
- Concerns that the daily rating process may distract from engagement in therapy, or “split” the treatment in some way; and
- Concerns for how privacy and confidentiality of electronically-collected data would be assured, and under what circumstances confidentiality may be breached, particularly in cases where patients reported thoughts of suicide?
Hopwood, C., Ansell, E., Pincus, A., Wright, A., Lukowitsky, M., Roche, M. (2011). The circumplex structure of interpersonal sensitivities. Journal of Personality Assessment, 79(4), 708-739.
Hopwood, C., Pincus, A., DeMoor, R., Koonce, E. (2008). Psychometric characteristics of the Inventory of Interpersonal Problems-Short Circumplex (IIP-SC) with college students. Journal of Personality Assessment, 90(6), 615-618.
Locke, K. D., Craig, T. Y., Baik, K., & Gohil, K. (2012). Binds and bounds of communion: Effects of interpersonal values on assumed similarity of self and others. Journal of Personality and Social Psychology, 103, 879-897.
Perry, C. J., Fowler, J. C., Bailey, A., Clemence, A. J., Plakun, E. M., Zheutlin, B., & Speanburg, S. (2009). Improvement and recovery from suicidal and self-destructive phenomena in treatment-refractory disorders. Journal of Nervous and Mental Disease, 197(1), 28-34.