Well, it's 10.30, and psychoanalysts have this thing about starting on time and ending on time, so we're likely to continue in that tradition. Thank you for coming. We have some surprises for you, and a lot of information, and so I hope you're in the right place. The name of the panel is On the Screen, Assessing Psychic Pain and Proximal States of Mind Associated with Suicidal Thinking and Behavior, a pretty heavy topic. My name is Eric Plakin, and I am the medical director and CEO of the Austin Riggs Center, where the researchers who've done this work are located. We live in an environment, long-term psychoanalytic hospital, intensive psychotherapy, completely open-setting a lot of very suicidal, treatment-resistant, borderline patients, and we somehow juggle freedom and responsibility in working with suicidal people. And so in the tradition of when you have lemons, make lemonade. We've had the opportunity to do a fair amount of lemonade-making around, oh, suicides. Not that we have so many people who die, but the issue is in the wind a lot of the time, and that's led to Jane and Katie doing research on the subject. Now, you know that children's book, Where's Waldo? Where's Katie? You can look all over the room, under the chairs, between the tiles. You can take down the suspended tiles from the ceiling. You will not find her. Katie is back in Massachusetts. Her effort to get here was interrupted by the joys of travel in the pandemic world and the weather and flight crews, and so I stepped up to chair so that I didn't leave Jane all alone for the time, but we're going to present her paper as well as Jane's. As we get started, though, it would be helpful to get a little sense of kind of who's in the room and why on earth did you come here today? I mean, you wake up on a reasonably decent New Orleans morning and you'll come to a place to talk about psychic pain and suicide. Why on earth did anyone come? And as you get up to answer, and I ask you to get up, please step to one of the microphones, and just be curious. I'm not going to ask everyone, but it would be interesting to have a couple of people just say, well, what are you looking for? And I'll also say the session is being recorded, so you don't have to say your name or where you're from if you want to remain anonymous. You can just go to the mic and ask your question, but we're interested in what brings people here and what about the topic interests you? Well, given that it's so hard to predict suicide, I'd like to be able to learn about some of the features of the state of mind of patients that might help me to be able to predict if my patients are at higher risk of suicide. That's why I'm here. Thank you. Great. Thanks. I mean, yes, trying to predict the unpredictable is so important, but at least knowing some things can help. Are people here mostly clinicians or researchers? How many are clinicians who treat people? Wow. Okay. So a great many. And how many are alternatively or also researchers who study suicide? Okay. A smaller group, but a number of people. Great. Okay. Anyone else have the courage to get up and say something about what they're doing here? So I was interested by the summary and the vignette, because as a young clinician, I kind of noticed that little attempt, it seemed to have like some kind of a psychic framework. So I was interested to know about the cases. Thanks. I'm a child psych fellow, and honestly, just kind of frustrated with the concreteness of a lot of approaches, especially when these kids are being institutionalized as we speak, and I feel like their answers become kind of rote. They've answered the same things over and over, and does it lack meaning at that point? So hoping for something different. Thank you. Great. Hi. I work in community health, and a lot of my clients have suicidal thoughts, and not only that, my son died by suicide two years ago, so it is near and dear to my heart, and I don't think it should be a stigma at all. I think it should just be a learning process, how we can help our patients, and even patients that we don't know. Thank you for saying that. You know, Richard Simon's forensic psychiatrist said something that has stuck with me about being a psychiatrist. He said there are two kinds of psychiatrists. Those who've had a patient commit suicide, and those who will. And it's an occupational hazard of the work that we do. Actually, the APA has officially recognized it as an occupational hazard of psychiatrists, and it has a huge impact, and not, you know, I think a different kind of impact, measurably a different kind of impact than deaths for medical, surgical illness and the impact on those clinicians, because part of our work is to make an emotional connection with the patient, and our patients are both the victim of murder in a suicide, and the perpetrator. So it makes for a very complex mix of feelings that we have to deal with. I see someone else. Yeah. Thank you for the opportunity. I'm in the process of designing a clinical trial in borderline personality disorder patients, and I would like to understand what we can do in order to safeguard the patients throughout the trial with regard to suicidality. Great. Well, these are all interesting things, and there's going to be more time for discussion, and we really want to encourage you, as you can tell, to sort of be part of the process. Jane has some things she's certainly going to deliver, but we also want to engage in a discussion and be able to conform what we're presenting to your situations and your needs. Otherwise, it's just a trip to New Orleans and some CME credits. We'd actually like it to be useful to you. So first, I'm going to introduce Katie Lewis in absentia, but Katie, it's terrible that she's not here, in my mind, because I just am so fond of Katie. She's just been appointed our Director of Research. She's a real sort of rising star in the world of psychodynamic research, and particularly around issues in suicide. So she's our Director of Research at Austin Riggs. She studies suicide in clinical and non-clinical populations. She's been the lead investigator in developing the psychic pain scale, and she also studies personality, loneliness, and interpersonal processes related to suicidal thinking and behavior, using the research methodology of what's called ecological momentary assessment to capture real-time experience. And then the other, so for Katie, it's in absentia, but I also want to introduce my colleague Jane Tillman, who really is the organizer of this panel. Jane is the Evelyn Stephenson Neff Director of the Erickson Institute for Education, Research, and Advocacy at Austin Riggs, and she's a clinical psychologist and psychoanalyst who's had a research interest in suicide for 25 years. She and I go back a long way, talking about treating suicidal patients, the impact of suicide on clinicians, and it's drinkable lemonade, if you will. So why don't I hand it over to you, Jane? Great. Thank you. So Katie's really sorry she can't be here. She had many canceled flights. She was on the tarmac in a rainstorm for three hours at Dulles yesterday, and another canceled flight. It just wasn't possible. She said she had a new encounter with psychic pain, which she had not anticipated. Apparently she was on the tarmac on a plane full of junior high students for three hours. So a bit of a rowdy crowd. But Katie had written out text for all her slides, and she was able to get off that plane eventually and send them to me. So I'm able to read Katie's presentation. So just want to let you know that neither Katie or I have any financial relationships with ineligible entities to disclose. We have the usual conflicts, but none of them that would affect this talk. No financial conflicts of interest. Our learning objectives for today, you'd be able to describe the role of psychic pain in suicidal thinking and behavior based on two research studies I want to tell you about. So I hope this will be interesting to researchers who we have a new research tool you might consider, the Psychic Pain Scale, which we've developed, and we would love to see that used in various research studies, because we want to understand more about the psychometric properties of that and how it performs in various clinical and research populations. We hope you'll be able to discuss suicidal thinking and behavior in the context of developmental psychopathology. You know, we're often focused as clinicians on identifying people who are at acute risk. Do they need to be admitted? What is the acute risk? And doing that assessment. But really, there's a long trajectory towards that final act of suicidal behavior. And what can we identify as upstream interventions that might help us understand how people arrive at that crisis moment? Because many people are only suicidal once or twice and they recover, but there are other people who are chronically and repetitively suicidal, and it's a recurrent experience for them. So we want to understand something about the developmental trajectory of those people. And we hope you'll be able to identify research-based states of mind proximal to a near-lethal suicide attempt. And that's going to be my research study that I'll present after I present the development of the Psychic Pain Scale. And finally, we hope you'll be able to assess multiple factors contributing to persistent suicidal thinking and behavior. I appreciated the person who said the suicide assessments can become kind of rote. Most people who have been assessed using our suicide assessment tools know all the answers. Some of them can answer the questions and say, you don't need to ask that. I can tell you the answer. And I think your question is exactly what we struggle with at RIGS. If you're giving a suicide assessment every single shift, how on earth do you make that meaningful? How is that a meaningful conversation? And meaning is so important beyond a kind of mechanistic checklist. So we want to have some ways of making a meaningful assessment of suicidal patients. So I'm going to add to some of Eric's questions here. And we're going to do a little show of hands straw polling, not electronic straw polling. But how many of you work with persistently suicidal patients, recurrently? That's a lot of people, right? So we know so much about trying to get at that moment of crisis and make a decision in a crisis. But we have to learn something about persistent suicidal patients and try to find a treatment for them beyond repetitive crisis assessment. What would be an effective intervention beyond that moment? Do you routinely use any screening tools or instruments in assessing suicidal patients? A few do. Anyone want to step up and say what you're using? I think this is a good exchange of information if people can say what kind of tool you're currently using to assess patients. If you could come to the microphone because the session is being recorded. And so they've asked us to make sure all questioners are at the mic, which is a little cumbersome. But thank you for doing that. Is it Columbia? Okay. We do, too. We use that. It's a great screening tool, right, if you're doing community screening. You can probably also just shout it out and we'll repeat it. Okay. Okay. That's a good idea. What other tools are people using? Okay. PHQ-9. PHQ-9. Yep. That's a good screening tool, right? Hopefully as an entryway to having a deeper conversation with someone, not a rule in, rule out, final decision-making tool. CAMS. CAMS. CAMS is a great system, Collaborative Assessment and Management of Suicide. You're assessing suicide and developing a treatment plan in a collaborative manner with the patient. This is David Jobe's work. We use a version of the CAMS at RIGS, too. It's a wonderful tool for not only screening but also treating, developing a treatment plan. So using the, you know, popular, what's available tools, that's great. And finally, what affects have you been taught, and there's a range of them, are predominant in suicidal patients? What are you listening for? What are you often taught to listen for in suicidal patients? Excuse me? A plan. A plan. Do they have a plan? What about the affects that might be involved? Anxiety. Anxiety. Anxiety, probably with some agitation. Yeah. That's a good one. Despair. Despair. Absolutely. Despair. Hopelessness. Hopelessness. Yep. Pain. Pain. That's what we're going to talk about today is how to have that entryway conversation about pain. We have a, one of the last slides of the presentation will tell you our theory about why that's important as well. So we know, listen for depression, pain, hopelessness, desperation, despair, anxiety, agitation, all these different things. So as you know, the suicide rate has been increasing in this country between 2000, 2018. It's gone up about 30% in that time, and in 2020, contrary to all our expectations with the pandemic, the suicide rate went down in this country by about 5.6%. So the United States sort of stands out in this, though, because worldwide during 2000, between 2000 and 2018, worldwide, the suicide rate was going down. So there's something in our country that we need to pay attention to about this. People are often interested in suicide rates by age. It's the age of 45 to 54 is the group. We are quite concerned about suicide in young people, and now suicide in children, but it's really between the ages of 45 to 54, according to the American Foundation of Suicide Prevention and CDC statistics, has the highest rate, and then those 85 and older have the second highest rate of suicide death. And I think this is a great cartoon. There were two epidemics. There was a pandemic and an epidemic going on in this country in 2020. As you know, firearms are involved in just over 50% of suicide deaths in this country, and when the pandemic hit, firearm sales skyrocketed to a record 22.8 million guns were sold in this country in 2020, and the FBI processed almost 40 million firearm background checks. It beat the previous highs by more than 10 million. So the pandemic scared people, and they bought firearms. So we expect that right now we're seeing a spike in homicides and gun violence, but that may, we have to pay attention to that, eventually have some bearing on suicide. So we've got a pandemic and an epidemic that we're trying to manage and understand if there's a relationship between those things. So there's a lot we know and don't know about suicide. Suicide's a little bit of a black box of mental health. We know at the epidemiological level some of the risk factors for suicide. We know it's a complex behavior with multifactorial causes. There's rarely a single cause for suicide. Yes, children may be bullied, but there are some other difficulties that may be going on as well. There may be a precipitating factor that leads a person to take action, but there are probably underlying factors that feed into that and make that moment so critical. So we know that there are proximal and distal factors. There can be that tipping point thing that happens, but there can also be developmental psychopathology, certain traits, certain predispositions to suicide that in acute stress then leads to action. So we know that stress is involved in creating the conditions for suicide, but acute stress or intolerable ongoing distress can be the precipitant. That's just another way of saying, I think, what I've been saying. But what's a mystery? We can't explain why extreme stress is associated with suicide behavior in some individuals, a few individuals. The base rate of suicide is very low, and so it's extremely hard to study it prospectively. So a lot of our studies are retrospective or limited to demographic descriptive data. It's very hard to do a psychological prospective study of suicide because of the low base rate. So now this is Dr. Lewis. This is what she would look like if she was here, although she would probably look tired and annoyed if she had been able to get here, and she looks kind of okay in that thing. She sent me her careful notes, so I'm going to present on her behalf. She is, as Dr. Plakin said, she's the director of research at Austin Riggs, and we've worked closely together for over a decade on studies focusing on suicidal thoughts and actions in both clinical and non-clinical populations. Katie's a full-time researcher. I'm predominantly a clinician and do research as a sort of part-time endeavor. So our goal today is to facilitate a discussion around conceptualizing and assessing states of mind that are proximal to suicide impulses and actions. Dr. Lewis's presentation focuses specifically on the construct of psychic pain, which is an experience reported by many suicidal individuals, including most of the patients who are suicidal at the Austin Riggs Center, speak of a kind of pain that we're trying to capture and measure and understand more about. There's several definitions of psychic pain in the literature, and most emphasize the constructs overlap with other negative emotions, such as shame, sadness, hopelessness, anxiety, despair. You all named those right off the bat without sort of missing a beat. These emotion labels help to illustrate in an evocative way the many potential dimensions that psychic pain may include. We think of psychic pain as an umbrella term that may contain a lot of differentiated affects based on the individual's experience. These labels, though, may be insufficient in differentiating psychic pain from closely related concepts like depression or hopelessness. Israel Orbach, who is a well-known suicide researcher, defines psychic pain as, quote, a wide range of subjective experiences characterized as an awareness of negative changes in the self and in its functions accompanied by negative feelings. This definition extends the idea of psychic pain to include the impact that the intensity of this kind of negative affective state can have on the experiences of the self and on self-regulatory capacities. American colleagues argued further, a unique feature of psychic pain is that it is experienced by individuals as both intolerable and unending. So it has an effect on the temporal experience. It's intolerable and it's felt to be unending. It'll go on forever. In borderline patients, that has often been described as various affective states that take on the quality that now is forever. What I'm feeling now is what I'm gonna only feel in the future. Psychic pain, according to Merrick and colleagues, has that sort of feature. And this combination of these two elements is believed to drive individuals to consider suicide as an option. It's a solution offering an escape. Balmeister has an escape model of suicide. Finally, Edward Schneidman, the patriarch of modern suicidology, wrote extensively about the concept of psychic pain, which he termed psychache. Schneidman incorporated psychache into his cubic model of suicide, which we show here. It's kind of tiny down there, but I think the resolution's pretty good. You might be able to see it. It includes dimensions of press, which are external stressors compressing against limited internal resources. So the stress exceeds the capacity and the resources to manage it. He also frames his model as involving perturbation, agitation, desperation, a sense of shrinking options for resolution, some of the things you identified, and the walls closing in kind of feeling. He argued that suicidal behavior is likely to occur when all these three factors of press, pain, or psychache, and perturbation converge in a way to create that condition. The Descent and the Suicide is the name of a paper that Terry Malzberger, the late Terry Malzberger, wrote and published in 2004. Terry lived out in Boston. We live out in the Berkshire Mountains of Massachusetts, so we're kind of neighbors in the commonwealth, and Terry was a consultant to our research group on developing our research project that I'm gonna present in a little bit, and in our work with Terry, we used that paper to try to build a theoretical model and a scale to measure psychic pain that is theoretically derived, and we used his work in The Descent and to Suicide. Unbearable negative affective states have been conceptualized by other clinical writers as representing part of a broader, more dynamic suicidal process, and this idea was explored by Terry Malzberger in his paper. Malzberger's model describes a process in which intense and unrelenting negative affect states, what he calls affective deluge, just a flood, affective deluge, leads to ego failure and disarticulation or disillusion of a self-representation. It's really a kind of affect that disrupts all kinds of self-states and thinking processes. In other words, a loss of reflective and metacognitive capacities, a loss of a sense of boundary between self and others, a loss of an ability to self-regulate, also a loss of control, and so these two elements, affective deluge and loss of control, play out in an unfolding process which gradually drives an individual towards suicidal action. While Malzberger's model is derived from his years and years of clinical practice and theory, indirect empirical evidence lends some support for his conceptualization. For example, with regards to affective deluge, studies by Herb Hendon and colleagues have reported that desperation was the affective, someone over here I think said desperation, was the affective state most frequently and strongly identified in patients by their therapist in the days prior to a lethal suicide attempt. So Terry and Herb Hendon worked together. They brought psychiatrists who had had a patient die by suicide in to be interviewed, and they asked the psychiatrist to formulate what had been the state of the patient from the psychiatrist's point of view that led to the death by suicide, and desperation was the sort of central affect that that group identified. And then with regard to the construct of loss of control, a study by Westide and colleagues in 2008 found that executive functioning impairments differentiated depressed inpatients with persistent suicidal ideation following a suicide attempt from those attempters who were depressed but whose suicidal ideation had subsided following the attempt. Often experiences of affective deluge and loss of control are described as occurring, co-occurring, occurring together. Herb Hendon, for example, in a 2004 study of individuals who had died by suicide reported, quote, each of the suicide patients who showed intense desperation had the perception of emotional disintegration, feeling that they were losing control of their emotions and their lives, and that the anguish they were experiencing had become intolerable, end quote. So in sum, while both affective deluge and loss of control are important to understand separately, ultimately they operate together to increase suicide risk over both shorter and longer spans of time. So these are a number of instruments and surveys that have been used to assess psychic pain over the past few decades. An article by Tasani listed at the top of the slide offers a lovely overview of these methods. With only one or two exceptions, each of these are self-report measures, and almost without exception, each measure is based on Edwin Schneidman's concept of psychic, meaning that they primarily target affective experiences such as sadness, shame, and self-criticism. Measures that include an assessment of loss of control have been conspicuously absent. So we don't have a good measure for that. Each of these measures also, in addition to our measure, has some psychometric concerns. So they're still in refinement, and this construct is still being worked out for measurement. In prior research conducted with these existing measures, psychic pain, conceptualized primarily as an affect state, has been consistently associated with reduced protective factors for suicide, including a sense of belonging and meaning in life, and also associated with elevated risk factors such as higher perceived burdensomeness and more severe hopelessness and depression. Existing measures of psychic pain, while helpful, they suffer limitations. First, the measures have been mainly sought to assess psychic pain using a single theory, which conceptualizes psychic pain in a very narrow range. A broader affective model is needed. Ideas related to loss of control are considered more peripherally or simply not represented. The concept of psychic has mainly been studied as an isolated construct rather than part of a broader clinical model like the cubic model. And the interpretation and application of findings to clinical practice has been limited because of this failure to more fully contextualize the findings using a broader theoretical framework. And finally, existing measures of psychic pain have mostly been used to address empirical questions, research questions about how psychic pain is associated with suicide-related outcomes. And while this is obviously an important endeavor, there's been little examination of how psychic pain relates to a broader sense of individual difference factors relevant to treatment, things like attachment style or personality functioning. So we need to put the construct in a larger context. So to address some of these gaps, Katie, myself, and some other colleagues developed a new measure called the Psychic Pain Scale, which aims to evaluate both overwhelming negative affective states and disruptions in reflective and self-regulatory functioning relying more on Malzberger's model. Our former colleague, Chris Fowler, who now is in Houston, developed an initial 20-item pool based on Malzberger's theory which we refined in a recent paper published in the Archives of Suicide Research where we ended up with a final 12-item version which includes two factors reflecting affective deluge and, importantly, loss of control, the variable that is tended to be left out of such measures. So here are the 12 items. And Chris Fowler wrote these items. I don't know what he was thinking when he wrote the items. The items in the dark blue are on the affective deluge subscale and the three items in the lighter blue are loss of control. But the items, the two factors replicated across both clinical and undergraduate samples and had strong internal consistency. We asked our colleagues at Michigan State University, Chris Hopwood and Evan Good, to give the measure to 900 undergraduates so we would have an adequate sample size for doing our psychometric properties. This allowed us to reduce the scale to these 12 items. And these items are kind of extreme. They're worded in a way that is much more, I think, captures a kind of horrendous experience of self and affect than other scales which have been a little milder about how often do you feel shame, how often are you depressed. These are things like I hate the person I've become. I feel like I'm dying inside. I don't know if I can stand myself for another day. I'm too damaged to get better. I feel like I'm drowning in terrible feelings. I have so many feelings I can't sort them out. When my feelings are intense, I can't think straight. So these are kind of measuring, I think, capturing something at the extreme end of the scale and extreme end of experience. And now that the scale's been published, we've gotten some lovely feedback from people who are using this in clinical settings and finding that it's 12 items, so it's pretty easy to give, and that the items provide a conversation or an entry point with a patient. You can go over the items and if people said, I feel like I'm dying inside, that introduces the language for having a discussion. You said you feel like you're dying inside. Can you tell me about what that's like? How long's that been going on for? So we also feel like the feedback we're getting from clinicians who don't just score something and say, oh, they got a 22, we're worried, but actually look at the items and use them to have a conversation with the patient. Very useful. This is the research data in our clinical sample of adult patients in residential treatment. That's our patients at Austin Riggs. We found that affective deluge factor showed a pattern of associations that was most similar to those findings previously reported in the psychic pain literature. It was associated with reduced protective factors and a higher frequency of past suicide attempts. The loss of control factor, while also associated with a prior attempt history, showed stronger correlations with an earlier age of onset of suicidal ideation. So maybe the earlier age of onset of suicidal ideation disrupts developmental processes that would allow a person to build resilience and to feel more in control and able to manage some strong affects. So loss of control associated with earlier age of onset of suicidal ideation, higher impulsivity, you would expect that if you're feeling a loss of control. Impulsivity can go up. A history of sexual abuse, certainly an experience in a child or a young person of not being in control. And some greater issues with impulse inhibition. We further found that the total psychic pain scale cutoff score of 22 served to best differentiate between psychiatric patients with and those without a prior suicide attempt history. And it seemed to be a score that undergraduate students were unlikely to obtain. So we were able to differentiate in clinical and non-clinical sample. In our, I think you might be able to squint and see some of this, but in our undergraduate sample, which is just over 900 students, interesting differences emerged between the two factors of affective deluge and loss of control in relation to broader personality traits and characteristics. Affective deluge was found to be most strongly associated with lower adaptive traits, conceptualized within the five factor model. And correlated with lower extroversion, openness, and agreeableness. It was also associated with greater difficulty in feeling warm or loving feelings towards another person. And associated with greater attachment avoidance. In contrast, loss of control showed stronger associations with attachment anxiety and problems being overly open, overly needy in relationships. Overly open, overly needy in relationships. Loss of control was related to greater neuroticism, dependent and borderline personality traits, and sensitivity to cold or withdrawn behavior in others. Both scales were associated with greater symptoms of depression, alexithymia, impaired interpersonal functioning. And taken together, I think the take home from all of this is that these findings show that psychic pain was associated with a wide range of individual difference factors. With the affective deluge factor capturing tendencies to withdraw or internalize. And the loss of control factor relating more to affective efforts to solicit interpersonal support and connection. Now I want to talk about clinical applications. I think most of you indicated that you're clinicians in this room. So we want to try, we're trying, the great thing about having the partnership that we have is we're trying to link research and clinical findings and do that bench to bedside translation as we develop our studies and think about their utility in the clinical setting. So now that we have a sense of how psychic pain has been conceptualized and assessed, we can talk about clinical applications. Individuals who are experiencing high degrees of psychic pain often have a lot of trouble describing it. Trouble finding words for it. Even after the pain has subsided, evocative metaphors like drowning or suffocating are often used by patients with greater verbal fluency to convey the sense of agony felt during a particular painful moment in life. And this is where the employment of a rating scale like the ones we reviewed today can be really useful as a clinical tool. It gives patients a range of items to rate. Assessors can offer an initial vocabulary. It helps people begin to develop a vocabulary for articulating painful experiences. And it also communicates through administering the measure that these kinds of emotional experiences are relevant. That we're interested in hearing about it. We want to know about that and have that conversation with the patient. Well, in my experience, patients tend to resonate, that's a good slip, resonate with the use of the word pain and additional language about feeling overwhelmed, trapped, lost or diffuse can open up the conversation to explore the nuances of this pain. And once psychic pain is introduced as a topic in psychotherapy, it can become a rich ground for clinical exploration. Also alliance building around a suicidal crisis and Eric and my colleague, Samar Habo, presented I think on Thursday or Friday, Saturday, one of those days, an alliance-based intervention for suicide that really speaks about how in psychotherapy you engage the patient with suicidal behavior in a conversation about how this is related to the alliance with the therapist. Patients, I think, may have a greater sense that the clinician understands and respects something about their reasons for their suicidal thoughts and the pressure that they feel under. And Katie says one of her favorite conceptualizations about suicide is that suicide is not the problem but it's the solution to the problem the patient in desperation has arrived at. Clinical scholarship on suicide, including volumes written by Schneidman, Malzberger and others, identify the reduction in psychic pain. If we can figure out something about that pain and how to reduce the psychic pain as a primary goal of treatment with suicidal ideation that we can make an effective intervention. Schneidman argues that flexibility in treatment is necessary in order to achieve this goal. Psych ache emerges from the experience of core psychological needs not being met. And I think particularly kids and youth and many people in the pandemic have had a tremendous experience that psychological needs are not being met. We can't meet in person, we can't socialize, the kids can't go to school in the same way. So there's been this massive social disruption that we now have to attend to as perhaps contributing to experiences of psychic pain. And therapy must engage the patient in an exploration of these needs in order to identify ways of reducing the pain. Someone back there said they use David Jobe's CAMS measure. One of the questions in CAMS that I think is so interesting and leads to an interesting conversation is what is the one thing that would have to change for you not to want to kill yourself? What's the one thing you identify? And that doesn't have to be a realistic thing, but it's the one thing that the patient is placing great weight on as causing their suicidal thinking. So briefly, our new measure of psychic pain that we're in the process of evaluating, its strength is a predictor of both momentary pain and the short-term emergence of suicidal ideation. We're using, Katie's using experience sampling methods across both clinical and non-clinical subjects. We plan to conduct further cross-validation studies with existing measures of psychic pain. And we seek to replicate the factor structure and existing nomological network findings across other diverse samples. So if you are a researcher and you're interested in adding this to your battery, or if you're in a clinic and you're interested in adding this 12-item scale to your assessment, we'd love to share it with you, work with you, hear about your experience with it, what you think is useful, what you think is sort of clumsy and doesn't quite work. But we're particularly interested in clinicians who use this as a way to open a discussion with a patient and increase the patient's vocabulary about having such a discussion. It's being used as part of our standard clinical assessment battery now at Austin Riggs. So we're also looking to gather data and further our understanding. So I want to stop now and see if there are any questions or thoughts or ideas you have about this psychic pain scale or tools used for assessing suicidality. And if you have questions or ideas, please step up to the mic. So if I were to use this, do I go online? Do I have to pay for it? How does that work? Or do I need to contact you in order to use it? Yeah, you could contact me or my colleague Katie Lewis is free. We're not in that business of marketing and making money on a tool. We really are interested in understanding the psychometric properties. Fuller, I mean, all the scales we mentioned before have some psychometric challenges and ours does too. So we're interested in that. You can just write us and we'll send it to you. And the paper is in archives of suicide that has all the fancy psychometric work that Chris Hopwood and Evan Good did for us. Okay, so you have an email somewhere that we would email you? Sure, I can give you my card after the presentation. I'm happy to give you. I love it, it looks awesome. Thank you. It's free, don't let... Okay. That was my question. Great, and maybe if you leave us your business cards, we can then just, with your email, we can just send it to you. Thank you. When I was reading through your scale, it was so painful even to read some of those items. And it occurred to me when I was reading it, when you're acutely suicidal, would it actually be, is it possible that it could be more painful or sort of endorsing these feelings or I don't know what I'm trying to say. Like if I was in that state of mind and I read that, oh, maybe they think I should be feeling this way. Like I wonder if any of your research has shown that it's actually been distressing for patients or somehow increased their risk. You are asking a great question I'm gonna get to in my talk about the study I did. That is a big worry. And there's actually research, thank you Marsha Linehan for doing research that shows that talking about suicide and giving very explicit questionnaires does not increase the risk of suicidal behavior. And I think patients appreciate that people understand something about how horrendous this psychic pain is. In our other scales that we reviewed, the items tend to be underhanded pitches. We work at Austin Riggs with people who are in extreme states of pain and we talk with them about it and it feels like this scale fits that degree of horrendous unbearable pain. Thank you for a very nice talk. This issue of pain interests me a lot because I work in Latin America and we do tend to express our psychic issues via the body, so people will actually talk about broken hearts or heartache. But then what I wanted to ask you is if you could please comment on this finding that was reported that psychic pain correlates with experiences of sexual and physical violence in the history of Latin America. Because in other types of literature, we recognize that the experience of violence is linked with higher rates of suicidal ideation, particularly during pregnancy for women, but it is attributed to higher impulsivity. And you have a different take. It has to do with psychic pain, so I'd like to hear your comments on that. We know from research on adverse childhood experiences, ACEs, that adverse childhood experiences increase the risk of bad outcomes, poor health outcomes, and poor mental health outcomes in later life, midlife even. And childhood sexual abuse certainly is an adverse childhood experience that is correlated across multiple studies with higher suicidal thoughts and behavior. Does that answer your question? The scale was really interesting, and one of the things that struck me was the fact of it was a lot of cognition, and I was wondering if you had some CBT more oriented therapist that used those questions as core belief to work with patients, and if there was any work around that. Not yet, but a trans-theoretical use of the scale, we would welcome that. We have so much to learn from one another about this. I think we can't be in our theoretical silos that we have to talk across disciplines, but I don't know specific to CBT if anyone's using psychic pain scale. And just maybe one more question. I was wondering if there was any work with that scale for what we consider like acute suicidality treatment such as ECT or ketamine or those kind of ER interventions? Not at this point. You know, really the Columbia Suicide Rating Scale is sort of a gold standard for that kind, and I don't think we're competing in that range at all. We're not predicting suicide with this scale. I think we're trying to measure something and bring it above threshold for a conversation. There's a man in the back who's been waiting for a long time, so we hear from you. Thank you for the excellent lecture. I just want to ask, since psychic pain is closely associated with lethality, has it been used to kind of like to measure outcome of treatment, specific treatments? We have not at this point. I said earlier in the talk, suicide has actually a low base rate. There's a lot of alarm and concern, and one suicide affects up to 60 people. It has a big fallout, but it's extremely hard to study suicide prospectively because you'd have to give this psychic pain scale to, you know, hundreds and hundreds and hundreds of thousands of people to get to an adequate sample size that would allow you to say something prospectively. I think that's part of how all suicide research is challenged, because the prospective studies are difficult. That's why we have such great big data about demographics, but not a lot of psychological data. Yeah. Hi. I work in the New York state prison system. We do a clinical suicide risk assessment. Actually, our social workers do it when the patients first come in from jails. Where would you fit this in? Where would you fit the 12 questions in? Would you, the patient would have to have a mental health assessment. I think if you're looking to, if you have a patient you're really worried about who can't quite put into words what the trouble is, could this scale help them begin to say something about their pain? If they had it screened, if they got a score of 22 or above, the cut score, that would flag something. But then, we would hope you would follow up and not just use this as a scoring thing. You know, so many times in so many systems there is so pressure for resources. People give a scale and they say, well, they got a 21, so we're not worried. Oh, that guy's a 25. He should go here. And scales are often used for management purposes. We would like this scale to be used not simply for management purposes, but for conversation purposes. Yeah. I enjoyed your presentation a lot, but I also wonder if all the emphasis on psychic pain makes us shortchange the impulsivity element, and I'm coming at it for two different directions. One is, as you said, a lot of us predicted that during the COVID crisis, when pain, despair, misery has certainly increased, suicide rates went down. My contention is that a lot of it went down because opportunities were decreased. Kids were at home. Most people were with someone and not alone in their thoughts, so the chance for impulsive actions was restricted, and tied to that is one strange thing in the suicidality. We look at depression. We look at PTSD. We look at anxiety disorders. I haven't seen too many studies from the suicidality range looking at ADHD, which has an extremely high rate of suicide. That's interesting. It's great we're looking at pain, but I'm wondering if by so much emphasis on that we're shortchanging. Yeah. I think there's room to study all kinds of different variables and all kinds of pathways. As an earlier slide, suicide's a complex behavior. It's multifactorial, and then how do all these variables come together? How does someone with ADHD who has psychic pain or substance use, which went up during the pandemic, how are we going to study and relate all these variables to understand this? I think it's really important, so ADHD is not one that we had included. Thank you. Hi. Hi. You're our researcher. Yeah, I'm a researcher. Thank you again for this amazing talk. I work with a lot of data, and I can see a lot of things that pop up, and I'm like, oh my God, yes, I want to measure this. But because we mainly work in clinical trials, and I heard you mention, say, this is something to open a narrative with, and when on the trials these things are measured, it's measured by a PI rather than the therapist that they're working with, and do you think it actually should be measured by a therapist, especially because it opens up the narrative to suicidal thoughts and behavior? Yeah. I think it's really important. Yeah. I think it's really important. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. At that point I think the question was about what are the best ways the students can measure suicidal thoughts and behaviors and ideation? First of all, to maybe improve therapeutic alliance, but also to open up some space for the participants actually to talk about the suicidal behaviors instead of the PI measuring it. We would love for you to use this in your clinical trial. We gave this to 900 undergraduates. And, you know, through the Michigan State's undergraduate psychology program most IRB protocols have a safety or a backup protocol. I don't, you know, as I'm sure your research protocols, if you're working with suicidal and depressed people, you have some backup clinical safety into your research. But I don't think to use a scale you have to then, it has to be a two-step process. So we would love any psychometric data that you get in a clinical trial. Yeah. Why don't we go on and I will try to get through the second study that I want to tell you about. And that is identifying proximal states of mind preceding a near lethal suicide attempt. This is a study I've done in collaboration with Dr. Lewis and my colleague Dr. Jennifer Stevens, Dr. Jill Clements. In this study patients at Austin Riggs were our participants and we interviewed a subset of those patients who had survived a near lethal suicide attempt prior to their admission to Riggs. I'll tell you about inclusion and exclusion criteria. I don't know if you have heard of the sociologist Arlie Hochschild. She wrote a book in 2016 called Strangers in Their Own Land. It was done here in Louisiana. That's why I thought I would mention it. She interviewed people here in Louisiana. She was interested in red state, blue state, or whatever differences among people here in Louisiana. And what she said in this book in the introduction of what she was trying to do is that people have deep stories about who they are and what their values are and that these deep stories don't need to be 100% or completely accurate, but they have to feel true. They're stories we tell ourselves that capture our hopes, prides, disappointments, fears, and anxieties. End of quote. We got to thinking, might the same idea be true about those who intend to die by suicide? If we listened and constructed an interview, could we hear a deep story, a story that feels true to the person telling it based on their emotional disequilibrium, most often a type of severe psychic pain? Because these deep stories say something about how we see ourselves in relation to our experiences and the words. They're kind of how we construct a version of who we are and how we have come to be that person and the culture we're in. So if we talk to people who've survived a near lethal attempt, will we be able to hear a deep story from them about their state of mind prior to their suicide attempt? So that was one aim of our study. We had several arms to this study, but the interview portion was about this deep story. This is the back door of the Austin Riggs Center where you can come in to work from the parking lot. And it's a beautiful back door. And Riggs is a really good place to do this sort of research. Forty-five percent of our patients have had a prior history of a suicide attempt. And our patients tend to be bright, verbal, thoughtful. They're all in four times a week individual psychoanalytic psychotherapy. And they're learning to put their feelings into words. That is a psychotherapy helps people put things that maybe they couldn't put into words before and then to try to reflect on the meaning of whatever their experience is. We had a subgroup of very near lethal suicide attempters who come to our hospital following maybe a stay in an ICU or some other psychiatric treatments. And when they're stabilized, they come to us. And we figured these are the nearest proxies to completed suicide. It's hard to figure out what the state of mind is prior to a suicide from someone who's died by suicide. Their suicide notes, only about 30 percent of people who die by suicide leave a note. Those notes are often apologies or instructions. They don't give a whole lot of nuanced detail about the state of mind. So we figured people who were alive by accident might be the nearest proxies for completed suicide. So we tried to get around the psychological autopsy as the only route to knowing something about that and use these people. Eric, you want to say something? I didn't know. Okay. Just to acknowledge all my co-investigators, Herb Hendon and Terry Maltzberger, sort of legendary suicide researchers, came and met with us. David Reese, who bent George Washington and NIH. Chris Hopwood from Michigan State, who's now at UC Davis. Robin Cree, who's now with the National Epidemiologic Intelligence Service. She was our statistician from Yale. So we had a lot of help. And we had some nice funding from the International Psychoanalytic Association and the Fund for Psychoanalytic Research. So we were happy about that. While we were waiting to get funding, we thought we better become experts on the methodology we had chosen. So we wrote a paper about the methodology we were going to use while we waited to get grant funding, sort of set up our project. And this is mixed methods research designed for pragmatic studies. Mixed methods research, if you're not familiar, combines qualitative and quantitative data. So we try to get the quantitative data and then make some meaning of it through using the qualitative data to illuminate whatever it is we're finding in the quantitative. And this multi-method kind of research is really now becoming much more common and recommended as a more robust research methodology. So we have some questionnaire data, and we have the semi-structured interview. This is basically our method and procedure. The people who did the interview, we met with them three times. Once to give the questionnaires, second time to do the research interview, and a third time to get a mood rating scale, martial in a hand, suicide attempt, and self-injury questionnaire. These were our participants. We had about 53% of eligible participants participate. That's pretty good for us. A lot of our patients are taking up their authority and decline to participate in research. And across several studies, 50% is really the best we've been able to do so far. We're working on it all the time to recruit people. So we had 131 people who got the questionnaires, and of those we kept 11 people to do these in-depth psychodynamic research interviews with. I'll go back. For our quantitative data, we gave the Connor-Davidson Resilience Scale and the Reasons for Living Scale. Those are two protective factor measures. And we gave the Barrett Impulsiveness Scale and our new Psychic Pain Scale, which we were piloting in this study. And, of course, this is retrospective data. So what we can say about these results is they show a snapshot in time of people who have made an attempt in the past. They don't predict a future attempt in our study design. They're like the shadow or the footprint of a suicide attempt. Perhaps resilience is lowered because one has made an attempt. Perhaps psychic pain results from an attempt. We can't say what direction it goes in. We see that Reasons for Living was a very robust measure. This is Marcia Lenahan's measure on classifying non-attempters, attempters, and near-lethal attempters, as was the psychic pain measure. We thought, wow, we're on to something with our psychic pain measure. In our study, impulsivity was kind of the dog of our measures. It didn't play out for us, which we were very surprised by, and which in the long term, because we're doing a longitudinal follow-up study. And so we didn't give the impulsiveness measure, and we're really sorry about that, because it turns out at time one impulsiveness is very predictive of who's dead at time two. But we didn't give it because it was so non-factor in this. And resilience came close to being significant in this study. What was interesting about our study is we had the lowest reported scores on a measure of resilience in the published literature. So sometimes in the past, people have thought of our patients as the worried well. They're not. Forty-five percent with a history of a suicide attempt and the lowest reported resilience score. This includes lower than Operation Enduring Freedom Veterans with a diagnosis of PTSD. The VA uses the Connor-Davidson Resilience Scale a lot, and so we were surprised to see that our patients in general were so low on this measure. Our patients reported fewer reasons for living, a protective factor, and high psychic pain, a risk factor, which is associated with past suicide attempt status. And for those making a near-lethal attempt, relationships that were perceived to be unavailable, empty, or absent or associated with betrayal were implicated in the decision to die. And we published the quantitative findings, this little self-promotion here, in Comprehensive Psychiatry and Psychiatry Biological and Interpersonal Processes, so you can sort of read about those measures. And then on to the qualitative data, because I think that's the most interesting. We used a method called interpretative phenomenological analysis, and it's a theoretically-based qualitative approach. It helps researchers gain an understanding of the psychological processes and themes linked to a particular situation, and then you can sort of sort the themes across interviews to distill themes that are common across all the participants. So we worked with Terry Malzberg and Herb Hendon to come up with a semi-structured dynamic interview, and we thought we'd ask about general thoughts and feelings at the time of the attempt. Can people reconstruct that for us? What's the acute context for the attempt? We wanted to attend to internal and external contexts, fantasies, dreams, stress, interpersonal context, details of the method. Why did you choose that method? Tell me about that. What did that mean to you? Did you think someone would find you? How certain were you that you would die? Those sorts of things. And what's it like that you didn't die? What's it like to have survived? So we had these audio-recorded interviews that we did with 11 of these people who had made very severe attempts, and many had been in ICU. We had one person who had set himself on fire. We had people who were on ventilators for prolonged periods of time, dialysis. These were serious attempts with great medical consequences for the majority of our interview participants. So here are some sample questions. These aren't all the questions, just to give you a flavor. Do you remember what you were thinking and feeling at the time you tried to kill yourself? What was going on that day? Walk me through it as you remember it, and we would prompt people to come back. Let's go back to that day. You said X happened. What happened after that? Right before you decided to set yourself on fire, can you recall what was going through your mind at that moment? Now there's a question of validity. How able are people to reconstruct their state of mind accurately? That's a good question. But as Arlie Hochschild said, there's a deep story that people have to tell about this, and the story is meaningful and I think does provide some clues, a road map as to how they got there. We asked this question because this is in our mind as clinicians. One of the things that torments clinicians who have a patient die by suicide is, what did I miss? Shouldn't I have known? That accusation sometimes made to clinicians, why didn't you know? So we asked these people, do you think anyone close to you could have known that you were going to attempt suicide? Did you hope that someone might have known? And I'll tell you a little bit about how disturbing the responses we got to this question were. These are demographic variables in our 11 interview participants, and because of time and it's only 11 participants, I'm not sure how meaningful this is, but what you can see is towards the bottom, the age of first psychiatric contact in this group is 13. Suicidal ideation comes later. It's not the presenting problem. The age of the first suicide attempt is after that. So the standard deviations are huge, so you can't make a whole lot of this data, but it adds some pathway to us to think about. Is there a developmental model of progression that leads people down this path to suicide? We gave people a questionnaire about moods, and we said, go back to that day that you tried to kill yourself, to the eight hours before. Can you reconstruct and put yourself in that frame of mind? Tell us what your mood was. Almost all the participants said depressed, hopeless, desperate, empty. What surprises us is we often think of people as being very angry when they attempt suicide. It's not very conscious or it's not something people are very willing to report, and raged is way down there at 2.25. This was an 8-point Likert scale that we asked people to rate these moods on. So while aggression is certainly in the mix and has to be addressed, it's not what these people report as being very conscious to them. But all the things you named, you know, you're familiar with are right up there as frequently rated emotions. So my colleague Jennifer Stevens and I worked to come up with the thematic categories that emerged across the interview transcripts, and these transcripts were long. This took us many years to do this. We identified developmental conflicts and crises. People had certain character traits and vulnerabilities. Interpersonal and object relations paradigms came up. Thinking and affect, certainly a big one. Fantasies of death. The paradoxical nature of the suicide attempt and reactions to survival. I'm going to read some quotes from the transcripts. I've selected them for this presentation to highlight psychic pain, which is cross-cutting across many of these categories. So it's embedded in many different ways in these categories. We have hundreds and hundreds of pages of data, and we don't have much time, and I want to leave some time for questions. So I'm going to fly through this and say something about developmental conflicts and crises first. Participants spoke of a crisis that was linked to a developmental challenge or a long-standing conflict embedded in development, like trying to leave home and go to college, or being middle-aged. As we know, that group between 45 and 54 has the highest rate of suicide, and this is, for some, when kids are leaving the nest, and there can be a big shift in identity going on at that time. So people in this category often spoke of suicide as a solution to the problem of separation or to some developmental crisis. So for example, upon breaking... This is from a college freshman, or someone who had attempted suicide during college freshman year. Breaking up with her first boyfriend left her suicidal. She made three suicide attempts, and the third, in kind of rapid succession, the third left her unconscious in the ICU with medical complications. And in the interview, she says about this breakup, we were each other's first, and I wanted it to be like the first and the last. I was literally his first kiss, so I believe he was this person put on the planet to love me and only me forever, and he was not allowed to like any other girls who weren't me. I mean, I guess growing up is like a series of learning that the world is not as magical as you think. So a kind of developmental problem about first love, about leaving home, about adolescent ideals that get disappointed and disillusionment. So that's one place where people can experience a kind of pain. Others in terms of character traits with rigid character styles might be particularly prone to chronic suicide in the face of stressors because of their limited range of adaptive capacities. And for younger adults, the lack of coping skills based on accumulated life experience. There was a perception that others didn't appreciate their psychological pain or vulnerability. Nobody gets it. Nobody understands it. So for example, a person said, I broke down and ripped out the meaning out of everything. I thought I was another brilliant human being running around and trying to make my life feel important, but when you look at things, when you zoom out, you look down on the world, we're just specks of dust. It's sort of like I'm in this trap and I'm thinking, why live? What's the point of this pain? We're just going to be buried in the ground. So again, this nihilistic sense of pain that sort of wipes out the meaning. Again, a young adult. Interpersonal and object relations paradigms. People spoke of a complicated experience of feeling intensely disappointed in other people. Having unmanageable feelings related to a sense of being betrayed by parents, friends, siblings, institutions, aspects of culture, significant others. One participant spoke of severing ties to others out of pain. This participant said, others weren't in my mind. I was in such pain. And that was the way I saw out of it. I wasn't thinking about anyone else. Later in the interview, the person said, I feel like I gave people enough of a chance and they blew it. I was done. Another participant told lengthy stories of feeling others who had neglected or bullied him deserved to be punished. And so this participant wanted to inflict pain on those by whom he had felt slighted and neglected. He said, I wanted really badly for the person who was still in town to walk in on me while I was standing there with a rope around my neck so that I could make a show out of me killing myself. Part of me wanted him to walk in so that I could say something dramatic and then just kick the chair out from under me. And one part of him, one part of me wanted him to try to stop me. I was in so much pain, I felt like he didn't care about me and I felt like he needed to be punished. This retaliatory impulse in the face of pain I think seeks to redistribute the pain to others. This is clearly an angry situation. One person described their psychic pain in terms of thinking and affect. And several people described psychic pain very succinctly as the pain was so intense there was no way to get it to stop. Another person, I was carried away in both instances. I couldn't get beyond how painful life had become. And another said my ability to think clearly in that situation was just so impaired. So I think I'll skip fantasies of death and the rest of it. You kind of get the idea. There's a kind of indescribable pain. And people then were left with a different kind of psychic pain when they felt, for some who felt remorse about what they had done to people and their families. And just some study, Ms. Laney, at the time of the interview, five of the 11 said they still thought about suicide as an option. And several of the people in our study have gone on to die. Our mortality rate at 7.5 years is about 10%, which is in line with the long-term mortality. Alcohol use was involved in four of the 11 attempts. Seven of the 11 had been recently discharged from a hospital. We know that's a high-risk time. Maternal death was an active issue in three of the 11. They had had mothers die under difficult circumstances. And separation from home, particularly from mothers, was part of the storyline. Our paper, States of Mind, Preceding a Near-Lethal Suicide Attempt, was just published in print in April. So here's our take-home about our theory about psychic pain. We think it's a proto-affect for negative affective states. So what might a proto-affect be? I will tell you what that definition is. A proto-affect is an affect that is unsymbolized, diffuse, unnameable, present, not fully differentiated. It's hard to speak about. We hypothesize that psychic pain may be the gateway affect, undifferentiated as it is, to the things we're used to talking with patients about, dysphoria and depression, which can lead to resignation and self-hate, to anxiety, which can lead to dissociation and numbness, and to anger and rage, which often include impulsiveness and aggression towards self and others. And often patients might be able to enter and tell you, like the guy who was angry, I wanted to inflict pain on people who had hurt me. He's able to start with anger and rage. And the pain is for other people. Some people can talk about anxiety, I wasn't feeling anything, I was numb. But we think psychic pain is an important way to have a conversation with people. Because for many patients, there is an ineffable, almost indescribable sense of internal pain that's hard to put into words. And so you might be able to get some traction in a conversation by starting there. And there is another reason I think this is important. I don't know about you. When I'm working with patients who are acutely suicidal, I feel anxious, I feel afraid, sometimes I feel very angry. I feel a lot of things. And we know from David Jobes and others, one thing that's important when you're assessing a suicidal patient is to be empathic. And it is much easier for me to be empathic with pain at moments and to use that as a way to center myself to be empathic with a patient who may have done something outrageous or something that totally ruptures the alliance. But how to get myself into that empathic conversation is important. Patients, I think, might have an easier time talking about pain, too. And so that may allow them to feel that you're understanding something that's sort of inchoate and not well-developed, but it's an entry point. It may involve less stigma for patients. You know, saying, I'm just an angry person can have a kind of stigma or be something the hot potato, the patient's not ready to deal with. They'll eventually have to get there if that's part of it. And I think, as I said before, using a psychic pain scale maybe provides an entryway into having that conversation because the items are most horrifically worded. It would be hard to just come out and ask someone a question like that out of the blue, but if it's something they've already answered and considered, you can do that. And so I think we have about 11 minutes to talk. So anything that's on your mind about psychic pain or working with suicidal patients, Eric and I would be happy to try to have a conversation with you. Thank you. Jane, I'm so glad you took a drink of water. It's been a tour de force and your voice was getting just a little rusty. It was. I haven't talk this much in a long time. You know, you usually listen. I've been Zoom with all my refreshments around me usually. So now it's your turn to speak more and to raise issues that you may have, please come to the microphones and we'll be happy to get going. Man in the back. I'm just curious about whether viewing pain as a proto-effect confuses us from also seeing it simultaneously as a very specific neurologically based symptom and that's going from the studies looking at people in psychic pain do seem to have activation of brain centers that seem quite analogous to some of the physical pain. So are we using semantically pain in two different ways when there may be two separable things to it? Again, a very specific neurologically based pain versus a despair, anguish. I think they might be related. I think it's a great question. I think they might be related. You know, assessing physical pain was one of the joint commissions 20 years ago. One of the vital signs. Pain was one of the vital signs. And you know, they had the smiley faces and the visuals because it's so hard to talk about. It's so subjective in some way. So I'm certain that there are neurological pathways and that I think there's research that shows there are common neurological pathways for both physical and psychic pain. I think I'm recalling that correctly. But how to get people to put it into words is difficult, just as difficult as getting patients to rate their physical pain is important, but it's complicated. I hope we're not favoring one thing in order to neglect another, but we're adding a tool to the toolbox so that we have more tools and can bring everything we have to bear on this conversation. Yes? So I have not so much a question, but a comment. I work primarily with patients who have cancer. A lot of them have difficult cancers and in palliative medicine as well. And so my comment is, I think it's also very important to talk about the other polarity with psychic pain, which is the meaningfulness of pain to patients. Many patients endure severe physical and psychological pain, but they go on because somehow they find meaning. And I think our work as clinicians really is to find a linguistic outlet for the kind of meaningfulness of the experience. And I think that that's the way out of the despair and the risk of suicide. Real quickly, I saw a patient with pancreatic cancer who happens to be a clinical psychologist very recently. She eventually died, and she did have this psychic pain. She happened to have a severe marital, spousal, physical abuse, and then she had pancreatic pain. And she saw the short period of time between diagnosis and death as a way to really process the meaningfulness of her life, enduring the trauma as she did with the patient. And so I think that gave her some sort of a balm for all the pain that she was suffering. And I think that that's just an important part of what we do as clinicians, is to really be present for the construction of that meaning. I think it's a very moving story, and to help people in extreme circumstances or end-of-life circumstances find meaning is probably the most important work we can do. Let me follow up on that just a bit, because I thought somewhere early on you were defining psychic pain, and the words intolerable and unending came up. And of course, I get that, that the intolerable and unending psychic pain sounds like, yes, that makes sense as proximal to suicide. But I think we're also using psychic pain the way we might use a headache. You know, I've got a headache, but I've got an intolerable and unending headache is different. So there's something about being clear about the specifics of psychic pain that are related to suicide versus the general sense of, you know, Katie's psychic pain, sitting on the plane and the runway in Dulles with the junior high school students for three hours, unable to get out of the plane. And I am, well, it was intolerable, and it may have felt unending, but she knew eventually something would happen. Right. The FAA rules would kick in. Yeah. So I just wonder about the use of the term kind of in both ways. I think that's it. I think psychic pain is its own, you know, maybe a broad category, but I'm sure there's a range in intensity. I'm sure there's a kind of chronic, low-level psychic pain, and then there is this suicidal kind of psychic pain of intolerable and unending. And it sounds like your patient knew her life was ending, that there would be an end, and that allowed her to make some meaning of what her experience had been. Great movie. Yes. Thank you. Thank you. That was an awesome presentation, really appreciate it. We hear things in different ways. So I saw your slide there with the proto-epic. It seemed to me that that would give us at least some hope for prevention, because you said the proto-epic, or your slide, indicated many states following, if you could actually intervene way upstream there, that looks awesome, and really defining sort of how it leads to the other states, and where you might link it up. You mentioned childhood traumas and those sort of things, that would be awesome. So working with the Columbia scale, we often, even the specific questions there, often don't net, you know, positive responses. I think giving other examples of very highly relevant questions, I think that's excellent, you know, broadening that out, because as much as we don't respond to a scale, when time gets tight, we often respond to a scale, and that's it. But having other ways to ask folks questions, and I would say I work at a state level with a department of mental health, and trying to do a broad suicide prevention program, you know, you have to think way beyond psychiatric clinicians, primary care, emergency departments, and you know, I think there just have to be other ways to ask these questions, because a lot of folks are just, you mentioned stigma also, I think are just not going to give that information, but they may clue in to being in pain, and really being in some suffering, and that may then prompt other interventions. And so, I really enjoyed this, and I think it's very, very pushing us forward in this regard. Thank you. Thank you. I was curious, in your qualitative study, you ask about who people told about being suicidal or who they didn't tell, and I just was curious about more, what did people say, tell me, say a little bit more about what, yeah. That was so sobering and very troubling to us. A number of our participants spoke about the lengths they went to deceive people. The deception was very, very sobering. We thought we would get, could someone close to you have known, we were looking for people to tell us what signs to watch for, and instead, people told us a lot of stories about their efforts not to let anyone know. Some of these were young, emerging adult types, and I think there's a developmental, little developmental triumph in there that was a little bit frightening. I think our more middle-aged subjects felt like they were protecting other people, and not letting them know. We didn't get what we were looking for, which is, tell us how we couldn't know. Hi. I'm wondering if metacognitive and executive function shifts are such a part of psychic pain. If there are specific recommendations for enhancing executive function, whether it's supplements, fish oil, B12 complex, even activities like doing puzzles, Sudoku, I know there's a lot of apps that are trying to enhance executive function by just thinking about certain calculations, math calculations, grammar, things like that. Or even certain medications, I know there's a lot of risks with stimulants and things like that, but to just enhance executive function, I wonder if that is something that would lower psychic pain scale ratings. That's a great question. I haven't thought about that. The question is, I think psychic pain diminishes with the affect of delusion, the loss of control. There can be a diminishment, at least temporarily, of some executive function, but I don't know about chronic and long-term, if these people have deficits in executive function. That's not something I know much about, but it's an interesting question. Hopefully this is quick. I know depression is usually what we think about when we think about suicide, but there's other DSM-5 diagnoses that are associated with suicide. I was wondering what other, besides depression, and maybe bipolar depression, that you saw in your studies that really connected with these people and their suicidal attempts. We treat a lot of people with personality disorders, and there's a certain kind of comorbidity, and Eric, I think you can speak more of the comorbidity issues than the suicide. Our average patient meets objective measurable criteria for six different disorders, usually a treatment-resistant mood disorder, personality disorder, substance use disorder, and other things, and I think that it's highly complex. One of the things I think that's really valuable about what we've been hearing is the way that it works to move beyond measurement alone, it includes measurement, to a kind of alliance building and the possibility of conversation with and joining with the suicidal patient. I think that's a really interesting development that stands to offer the field something so that in addition to monitoring, there's a kind of joining that I think in the long run is more likely to have an impact than measuring alone. We're done, huh? Yeah, I guess we're kind of done. Thank you all. Thank you.

psychic pain

suicidal thinking

suicidal behavior

Psychic Pain Scale

emotional aspects

self-regulatory aspects

intense pain

loss of control

emotional overwhelm

psychometric properties

clinical applications

risk for suicide

meaningful conversations