An Interview with Craig Bryan, PsyD, on Preventing Suicide
Dr. Bryan discusses his suicide prevention research which has been shaped by his experience as an Air Force clinical psychologist in Iraq working with active duty soldiers. Though suicide is a leading cause of death in all age groups and populations, traditionally, rates of suicide associated with the military were lower than in the civilian population. Since 2009 rates of suicide in military populations have surpassed civilian rates. This is due in part to the inherently stressful and volatile nature of military work, but the relationships are not straight-forwardly due to PTSD as the rate of suicide is higher among non-combatants than those exposed to combat. Paradoxically, many soldiers report that combat is less stressful than non-combat situations.
Dr. Bryan recommends training soldiers in problem solving techniques as an effective means of suicide prevention. Though soldiers typically reject efforts to talk about mental health issues, they are generally open to learning more efficient means of coping and problem solving. This is often best delivered as leadership training so that military commanders can be the ones to teach effective problem solving skills. A leader's ability to identify problems before they become crises and to show respect for soldiers' morale also emerges as important protective factors.
David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show, we'll be talking with Dr. Craig Bryan about his work in suicide prevention, both in the military and civilian populations. Craig J. Bryan, PsyD, is assistant professor in the Department of Psychiatry at the University of Texas Health Science Center. Dr. Bryan received his PsyD in clinical psychology in 2006 from Baylor University and completed his clinical psychology residency at the Wilford Hall Medical Center, Lackland Air Force Base, Texas.
He was retained as faculty in the Department of Psychology at Wilford Hall Medical Center, where he was chief of the Primary Care Psychology Service, as well as the suicide prevention program manager for Lackland Air Force Base. Dr. Bryan deployed to Joint Base Balad, Iraq, from February to August of 2009, where he served as the director of the Traumatic Brain Injury Clinic at the Air Force Theater Hospital, a primary Level III trauma hospital in Iraq.
Dr. Bryan separated from active duty service shortly after his deployment and currently researches suicidal behaviors and suicide prevention strategies and psychological health and resiliency. He is currently the project director for a $1.97 million study testing a cognitive-behavioral psychotherapy for suicidal service members. He has additionally chaired the American Association of Suicidology's Primary Care Task Force to develop training curriculum for primary care medical providers in the assessment and management of suicidal patients.
Currently, Dr. Bryan is lead consultant to the U.S. Air Force for psychological health promotion initiatives and to the U.S. Marine Corps for suicide prevention. He regularly provides training to clinicians and medical professionals about managing suicidal patients and has dozens of publications in the areas of suicide and military mental health, including the forthcoming book Managing Suicide Risk in Primary Care. For his contributions to primary care behavioral health and military suicide prevention, Dr. Bryan was recognized by the Society for Military Psychology with the Arthur W. Melton Award for Early Career Achievement.
Now here's the interview.
Dr. Craig Bryan, welcome to Wise Counsel.
Craig Bryan: Oh, thank you for having me.
David: One of my listeners, a social worker by the name of Sean Williams, who currently lives in Colorado, suggested you would make a great guest. He's given me some good leads in the past, so I'm very happy to have you on the show. Does his name ring a bell?
Craig Bryan: Oh, yes, absolutely. He's one of my employees.
David: Oh, okay. No wonder he recommended you, then.
Craig Bryan: Yes, yes, he's working with us on a study, and so, yes, I know him quite well, actually.
David: Well, that's great. I have just had online contact with him, but I really liked the contact that we've had, and as I say, I trusted his recommendation. Sometime back I also had Thomas Joiner on the show talking about suicide. Perhaps you know him.
Craig Bryan: Yes. Actually Thomas and I know each other quite well. We've done a lot of work together, and we continue to work together.
David: Okay. Well, before we get into the topic of suicide and suicide prevention in the military, which is kind of my main focus, I'd be interested to find out a bit more about your background. I understand up until recently you were a psychologist in the Air Force. Which came first - becoming a psychologist or joining the Air Force?
Craig Bryan: Well, they kind of came at the same time. I went to graduate school at Baylor University. And to become a psychologist, of course, before you can receive your doctorate, you have to participate in a full-time pre-doctoral clinical internship, and so what I did was I decided to join the Air Force to do the internship as a part of the Air Force's training program. And so I applied, I interviewed, and you have to go through all of the military entrance requirements and physicals, things like that. And once I basically passed all the tests, I ended up matching with the Air Force site in San Antonio at Wilford Hall and did my clinical internship there. And then after the year of internship, I received my doctorate, and then I continued to serve for three years afterwards. When you do an internship in the military, you do your one year of training and then you have a three-year commitment after that. You sort of pay back that time and that training that you received with several years of service.
David: Yes, I wanted to ask you about that. I know way back when I was looking at graduate school options, there were various kinds of incentives that the military offered where you could pretty much get your graduate school education paid for. Does that sort of thing still exist?
Craig Bryan: Yes, actually the Air Force and other branches as well. I know the Army has; I believe the Navy as well. They have Health Profession Scholarship Programs they call HPSP. Now, that was not available for me. They actually started it the year after I joined, so I wasn't able to benefit, but we do have applicants now while they are in graduate school can apply for this program through whichever branch they are interested in. They do interviews. They have to go through all the qualifications for military service, and if they are selected by the board or the interviewers who ultimately talk with them, then it's basically just a scholarship. You go to school and the military helps you to pay for your tuition, your books, your fees, all those types of things.
The alternative other programs that they have within the military are loan repayment programs, and so after you have come in, you've started to serve, you can apply it sort of like a scholarship program again, as well, where you just send in your information. You apply and then a board selects certain recipients and winners, and they will pay off a certain percentage of whatever student loan debt you have acquired.
David: You know I asked you that question, and I realized as you were answering it that I totally had forgotten that actually I won a Naval scholarship to go to college, and I ended up turning it down because I got a scholarship with no strings attached.
Craig Bryan: Right.
David: I'd kind of forgotten about that, but that wasn't for graduate school, though, that was for undergraduate. Do you come from a military family yourself?
Craig Bryan: No, actually. I do have like a second cousin who's in the Army National Guard. One of my uncles served in Korea; he was drafted for Korea. And, of course, my grandfather was in World War Two. I think my generation everyone's grandfather seemed to be in World War Two. But that's basically it. We're not kind of that traditional military family with lots of family members serving.
David: Yes. And after you passed all those tests, you got commissioned as on officer, right? Do you get commissioned as an -?
Craig Bryan: Correct.
David: As a captain, do I recall? Or as a -
Craig Bryan: Yes. As I psychologist, yes, you're commissioned as a captain.
David: Okay. Well, so then you were deployed in Iraq. What can you tell us about your time there?
Craig Bryan: Well, I could tell you lots. I think it was one of the most important experiences that I've had in my life. I joined the military to have an experience like deployment. I certainly did not know at the time that I joined that I would necessarily be going to Iraq, but I did know, when I joined - and the reason for joining was that there are men and women who voluntarily walk towards sources of death and harm and injury, and they place themselves in those situations intentionally for the good of others. And whatever that good is will differ, but there's some sort of good that they make this decision to place themselves in harm's way.
And of course the cost of that can be very great psychologically. There can be a lot of suffering that results. And so I ended up joining the military because, as a psychologist, I realized that I had a very important role to play in helping these men and women who make this sacrifice, to help them live their lives afterwards with as much quality and as much purpose and meaning as we possibly could. And that was - when I was in Iraq, that was very, very salient, very real to me on a daily basis, where you're working with service members who just hours before were in a gun battle; they were blown up by an IED; they were being injured; they were coming close to death; and they were being sent to us to treat their injuries both physically and mentally. And it was the most important and the most rewarding experience I've ever had.
It was also in many ways the most challenging experience that I've ever had. It was very difficult, for a variety of reasons, to be deployed, but I think it's because it was challenging that's why it was so meaningful and such a positive experience for me.
David: Wow. I recently read Sebastian Junger's book, War.
Craig Bryan: Yes, it's a great book.
David: Yes, an incredible book. It really made - it kind of puts the reader there. It feels like you're there, and then I saw the film that they made I guess that same time: Restrepo I think it was called.
Craig Bryan: Right.
David: And, boy, it just brought up all sorts of feelings that I won't go into here, but very, very powerful. And, according to your bio, you were in a primary Level III trauma hospital in Iraq.
Craig Bryan: Yes.
David: So what does that mean - primary Level III?
Craig Bryan: So in each of the theaters - so Iraq and Afghanistan - you have different tiers or levels of medical care. And of course the lowest level is those field medics. They're the soldiers, the Marines, the airmen, the sailors, who are out there on the battlefield, embedded in the platoons and the units, who provide immediate first aid. Whether it's a combat injury or even just regular, everyday nausea, vomiting, those types of things.
And then of course individuals who sort of exceed that level of care are then pushed to larger installations where they have more medical facilities or they might have a physician or a physician's assistant or a nurse practitioner, something like that, who kind of serve as almost like a primary care physician. And then above that you have sort of the combat support hospitals or like small, surgical centers where people go for that first level of care for the more severe injuries. And then you have the next level, which is sort of the larger-scale combat support hospitals, where you have multiple disciplines. It might be a tent or it might be hardened facility, depending on the location, but just basically that's sort of the highest level of medical care that you can receive in a combat zone.
And what most people don't realize is that the medical care at those facilities are actually much higher than what they think we have. We have CAT scan machines, radiology machines. You have lots of surgical specialties. You have different medical specialties as well: physical therapists, of course mental health professionals. And we're all working together because we're sort of the last stop. If we can't treat them effectively, then the next step is to send them back to the United States via Germany usually.
David: Um-hmm. What's it like being a psychologist in the military? Can you give us some of the pros and cons in case any listener is considering it?
Craig Bryan: Yes. Well, I think the biggest pro is you're working every single day with men and women who, like I said, place themselves in harm's way voluntarily, and less than one percent of our population in the United States does that. And it's just very different to work with those individuals and their families and their children. You also get to work with retirees as well, so those who have served in the past and are now continuing to receive medical care through the system.
And there's something about wearing the uniform that, particularly when you're working with other service members, it's hard to explain but it's just different. When that soldier or that Marine or that airman walks into the office or the exam room and you're wearing a uniform, there's something very different about how they'll interact with you, and it's almost like there's a shared experience that you can't necessarily get when you're a civilian provider.
The cons: I guess the downsides is that in the military it's a large bureaucracy, and things change constantly. Your life is perpetual change, and so something that you were doing, a project you were working on for several months - you know an event happens somewhere in the world and all of a sudden priorities change, and all the work that you've done doesn't matter any more because the military's been called or politicians have changed laws or rules, and so that can be a very difficult life in that sense. I think that's where most people have the most stress within the military, is that, in many ways, you can never really expect things to stay the same because it's constantly changing, and so there is an instability that comes with the life that you just need to have a certain level of flexibility to be able to manage.
David: That sounds like good training for life in general.
Craig Bryan: Oh, it absolutely is. That's been my experience that sort of that ability to kind of roll with the punches and maintain that flexibility is extremely, extremely important because, working outside the military now, there have been many situations like, well, this is nothing compared to the change that constantly occurs within the military. And so you find that you can be a lot more patient. You just don't get as upset with things as much.
David: Interesting. How did you come to be interested in suicide?
Craig Bryan: Well, I think I've always been interested in psychology, and I know it was as far back as high school is where I guess you could say sort of the career trajectory began. And I think close behind that there has been a fascination with that sort of mindset that someone is suffering so intensely that they perceive the only option for them is to terminate their existence. It's a decision process; it's a mindset that is very, I think, confusing. It seems counterintuitive to many people, and we don't understand suicide as a result. I think just widespread throughout the world and particularly within the U.S. culture, suicide is very misunderstood, and so it's always just kind of intrigued me: what happens in the moments immediately preceding that decision?
And once I got to graduate school, my training director, Dr. David Rudd, who is a very well-known suicide researcher, just provided supervision and really kind of fostered that and gave me the opportunity to write a paper with him on suicide. And that was the first major project that I did focused on suicide, and just pulling articles, reading books, and writing up this paper, it just really solidified for me this is what I want to do and this is what I want to focus on.
And working with suicidal patients is something that I've just always found very rewarding as well; just being able to help someone who is suffering that much to really kind of get them to move to a place where they can start living a life that's worth living, and you sort of like render suicide obsolete. It's sort of like you've defeated it in many ways. It's a very, very rewarding experience.
David: I'm struck by your observation that, particularly in this country, suicide is misunderstood. How so?
Craig Bryan: You know, when I do trainings and lectures and classes on suicide, I usually start off with the basic statistics. Kind of like any class that you go to where you're learning about a health condition, you always start with statistics and the prevalence rates, things like that.
Craig Bryan: And what I have found is most people are most shocked by - and you can go to the SDC website and you can pull data on how people die from a population standpoint, and we see this all the time in the news and magazines, and things like that, where it'll say, "This disease or whatever is the X-leading cause of death." You can pull that data, and what you see is that suicide is consistently among the top ten reasons for death, and that for at least about one third of the average life span - so up until the age of about mid-30s and sometimes kind of creeping up close to the 40s - suicide is actually among the top three causes of death. And so you have suicide contributes to more deaths than homicide, than many of the diseases, many of the health problems and medical conditions that we often think about as being major mortality risks. But most people don't know that.
David: Yes, that's news to me, actually. I'm a psychologist. I should know that, but I'm surprised to hear it. I think we have this perception, the stereotype, that the Japanese commit suicide, but it sounds like Americans are committing suicide at an incredible -
Craig Bryan: Right, yes. Well, everyone's dying by suicide, not just any particular culture or nationality. It's something that it seems to cut across all cultures. It's something about the human condition. But interesting enough, it's not even limited to humans. That's another myth is that only humans kill themselves. And you mentioned Thomas Joiner before. He's actually written extensively on self-enacted death amongst the animal kingdom and even the plant kingdom, so there seems to be something within just the biological makeup of living organisms that contributes to this sort of behavior, so it's not quite an assumption that says, well, this is something that humans do and it's something bad. We have lots of negative things associated with suicide, and it certainly is an undesirable outcome, but it's not quite as confined and simple as people would suspect.
David: Well, I have to hear an animal example because this is surprising to me as well.
Craig Bryan: Right. He actually, in one of his books that he recently wrote - the most recent one that came out it is Myths About Suicide. It's a great book, and I would encourage anybody to read it. He has some sections in there where he talks about - I'm not going to remember the insect species, but I think it's like an ant or a spider, something like that, where - and we see it actually in several insect species, where the male will mate with the female and then promptly be killed by the female, which we typically think of a homicide sort of situation, but in many ways, if you think about it, it's like, well, but - what is it? You would think that over years and years and years, evolution would have sort of figured out maybe we should stay away from the females who are going to kill us. But for whatever reason, that has not changed within the species pattern, and so there must be something innately important or functional or we don't really know what, but there's something there within the species that we're seeing this intentional self-enacted death in some way.
David: What about in our closer relatives? I'm thinking of the great apes.
Craig Bryan: Right. There's actually been some documented evidence of self-injurious behaviors amongst primate species. There was one study in particular that I read several years ago where they actually looked at different regions of basically primate brains - and, again, I don't remember which species of primate it was - but what they found is that damage associated with particular brain regions, particularly the frontal lobe area, was associated with increased biting behaviors, so intentional biting to function as some sort of self-injurious behavior. And so they have seen it in primate species as well.
David: Okay. Now, did you have some involvement with the study of suicide as part of your military involvement?
Craig Bryan: Yes. While I was active duty, actually we did several small studies. You know when you're in the military, at least the job that I was in, my particular, my primary job was to see patients, not to conduct research. But I was also in charge of suicide prevention at my base, and so we did several small studies just kind of looking at sort of how are people responding emotionally to suicide prevention activities; and, in particular, when they watch some of the videos that were designed for suicide prevention, does it make them feel worse? And interestingly what we found was the opposite: that people tend to feel better after watching suicide prevention materials. We did studies within my primary care clinic as well, looking at screening, endorsement rates, things like that as well.
David: So what can you tell us about suicide incidence rates in the military, and maybe how those compare to civilian rates?
Craig Bryan: Traditionally, suicide rates within the military have been lower than in the civilian setting, kind of the general U.S. population. Now, one thing that's important that you have to do when you're comparing military to the general population is you always have to adjust for age and gender, because the military is much - has a much higher proportion of males than the general population, and the military tends to be much younger on average than the general population. And because age and gender are significant risk factors for suicide, you have to kind of account for that to balance the playing field; otherwise it's not a fair comparison.
And so, traditionally, when you look at those age and gender adjusted rates, we've seen that the military is lower, but right around 2004 we started to see the military rates rise. They started going up slowly and gradually. Then about I think it was 2008 - maybe it was 2009 - is where we saw within the Army and also in the Marine Corps where their suicide rates matched the civilian rate and actually exceeded the civilian rate.
So it was quite alarming in that sense because military service really has, in many ways, traditionally been thought of as a protective factor, because we do see lower suicide rates amongst the military. But something changed within the past about six years, where something is happening now within the military that it's no longer functioning in that same protective factor at a group level like it used to.
David: Would that be - have something to do with our involvement in Afghanistan and Iraq and PTSD?
Craig Bryan: Yes, that's one of the leading theories. I think it's much more complex than that. What most people don't realize is that the majority of service members who kill themselves actually have never been deployed, and so the common assumption is you're in the military; you go fight a war; you get PTSD; you come back and you kill yourself. And that's sort of the sequence of events that I think most people believe is happening. And that certainly is the sequence that seems to be happening for many service members. I don't want to say it's not happening at all because that is sort of what seems to be happening.
But for the majority of the suicides in the military, that is not the sequence. It's they've never deployed and something else seems to be triggering the suicidal crisis, and I think what we see most commonly: relationship problems, financial problems, disciplinary problems - so life stressors, kind of everyday life that creates some sort of a crisis, and it causes suffering. And the service member is unable to effectively cope with it and arrives at death as the solution to this problem. It's a faulty line of thinking, but that's kind of where their mind goes. So it does differ quite a bit from I think what most people assume is happening right now with the military.
David: I wonder if service people who are actively involved in combat sort of have less psychic space for inner anxieties and are sort of more focused on the external threat, and if that somehow provides a certain protection against suicide.
Craig Bryan: We're not really sure. I think it's sort of interesting because combat is a risk factor for suicide in many ways. It's a risk factor because you're exposing someone to trauma; you're separating them from their social support networks; usually you're sleep deprived; you're constantly going; you don't have downtime; you can't just go catch a movie and unwind. So there's all this constant, pervasive threat that serves as risk factors. Yet at the same time, combat can function as a protective factor, because what most service members will report is that when they are fighting in combat, their sense of purpose and meaning is significantly increased.
Craig Bryan: There's a clarity to what they're supposed to be doing in life that protects them.
Craig Bryan: There's increased camaraderie, cohesiveness, and so it's not - I think the role of combat is much, much more complex than what we have typically thought of it right now, and I think that's why within the military a lot of us a really [unclear]. We can't approach our assumptions of suicide with service members using the same beliefs and assumptions that we have for civilians because there's a different experience. When we think about shooting someone or being shot at, to those outside the military that sounds horrifying. To many service members, however, they'll report adrenaline rush, a high. They'll say it was exciting. Some will even say they feel calmer when they're in combat, and they're restless all the other times. And it seems confusing to civilian and the outside of the military, but that is the nature of service members. That's just how they work; that's how they think.
David: Yes, some of that really came through in Sebastian Junger's book that we mentioned earlier, War, and you realize that a lot of these young service guys are guys who grew up on video games and that kind of excitement, and that in a way it's testing them as young athletes - and not to glorify it, but this is some of the reality of that particular age group.
Craig Bryan: Yes, and I think that's a lot of the work that some of us are doing now with service members. We're taking a very different approach to how we talk about psychological health and the role of combat, and I think this is one of the ways that my deployment really sort of affected how I look at health and mental health within the military, is taking that positive strengths-based approach.
In the mental health field, we talk about risk factors and disorders and symptoms and signs and combat as a risk, and separation from family as a risk, and all the ways that life experiences make you sick or ill or deficient in some way. When you work with service members, however, yes, they sort of look at these adversities, by and large, as their challenges to overcome, and you become better and stronger. And so they are athletes.
I mean if you ever have the privilege of going to a combat zone, you see these guys are carrying 100 pounds of gear; they're walking miles every day; it's 100 plus degrees; they're often dehydrated; they're sleep deprived; they're doing manual labor over and over and over again. These are athletes. I mean it takes a very high level of conditioning. And so if you come at them and say "there's something wrong with you," you're not going to have much success, and I think this is where mental health stigma directly comes from. But if you approach them as "you're world-class, elite athletes, and what I'm going to do is teach you some skills to make you bigger, faster, stronger," they really resonate with that.
And really that's what we're doing from a mental health standpoint. We're trying to help people become stronger, to become better at what they do, to live lives that are worth living. But we kind of get entrenched in this sickness and illness-focused perspective, and we sort of forget all of the strengths and all of the positive things that can result from life challenges.
David: Well, I wonder if you're aware of the University of Pennsylvania psychology professor Dr. Martin Seligman.
Craig Bryan: Yes.
David: And his creation of something called positive psychology. And I've read that he received some millions of dollars from the Department of Defense to create a program designed to build psychological resilience among U.S. service people.
Craig Bryan: Yes.
David: In a way, that sounds like what you're talking about. Are you aware of his program, his work? What's your take on it?
Craig Bryan: Yes. No, it's Comprehensive Soldier Fitness is the program that's kind of stemmed out of Seligman's work, and I'm very familiar with him, and I've read much of his writing and his theory, and I think I have incorporated a lot of that within my clinical work. So when I'm working one-on-one with that patient who's coming in for some problem, I've started to sort of modify the way I talk about psychological health issues, medical issues, and frame it from a more positive growth perspective. And I've also incorporated those ideas in sort of the prevention activities as well, going out and trying to keep people from developing PTSD depression and becoming suicidal in the first place.
David: You mentioned videos earlier. Is there anything the military can do or has done to ameliorate the contributory factors to suicide?
Craig Bryan: Yes, I think there's a lot that can be done, and importantly it's - we talk about the military quite a bit, but really many of the same ideas that would work in the military would work just in general across the U.S. population. But some of the things that I often work with military leaders and commanders on are looking at quality of life issues, and I really kind of look at mental health issues in general and suicide in particular from more of a public health standpoint. And I think that's another difficulty that we've had within the military, within the U.S. general population, is viewing suicide as a medical condition - and it is a health problem - but not kind of looking at it from the more public health population standpoint.
And the analogy that I give is, if we want to prevent a flu outbreak - several years ago, H1N1, everyone was talking about that - the way that we prevent a flu outbreak is not to post warning signs and symptoms of the flu and say, "When you have a fever and you're feeling really bad and you have a cough and you're feeling sick, go to the doctor and get medicine." If we took that approach, everyone would have the flu. But when we're looking at infectious diseases, we tell people cover your mouth when you cough; wash your hands; don't share glasses; stay home from work when you're sick. So we try to prevent the spread of illness from one to the other, and we do it on a group level, importantly. So the whole philosophy is try to keep people from getting the flu in the first place, and then you don't have to worry about a flu outbreak.
And so when you look at mental health issues, and particularly suicide, if we take that same philosophy of let's look at this at the group level and increase the quality of life for everybody on a daily basis by addressing small, little things that don't seem that important. You know, washing your hands doesn't seem like a huge thing, but it goes so far in preventing disease.
So if we can have commanders work on management style: how do unit members get along with each other? Do they understand their purpose and their mission? Is there good morale? How often do people get days off? Do they have to fight to take leave? When someone is having family issues, are they allowed to go and address them, or are they given grief for taking time off of work?
And those are the types of things that we look at within the military. That's sort of how you prevent suicide on a global scale. But if you kind of do the "here's the warning signs, and if you have these, go to mental health," that's a good approach, but it's sort of like it needs to be augmented. That can't be the only approach. It has to be supplemented by this population public health approach where you try to strengthen people's psychological health every single day.
David: Yes. So, in other words, kind of an epidemiological approach. It suggests a possibility of some degree of emotional contagion, maybe, as both potentially a negative and/or a positive factor.
Craig Bryan: Right. Yes.
David: And I'm wondering if part of the treatment approach, or the inoculation approach if you will, might have something to do with trying to educate people about attitudes - positive attitudes, positive mental habits, if you will.
Craig Bryan: Yes, it is. Interestingly enough, when we think of the concept of suicide contagion, suicides - they don't really spread from one person to another like an infectious disease does. When we see these, they're more like clusters. What you'll sometimes see is several suicides or suicide attempts within a small group of people. So maybe it's a military unit or maybe it's a school system, something like that. And when these clusters occur, what usually seems to be the case is that there are common risk factors, so it's not that one suicide is necessarily triggering another, but that all of them are existing within the same system, and the system is affecting all members in some way that is increasing their risk for suicide.
And so what we do then is, yes, you work with the - whoever's sort of in charge of that system or who has a positive impact on the entire system to identify those factors to correct them and to take steps to use the system to sort of strengthen everybody and make them healthier, make them more resistant to suicide. And one of the most interesting factors that we think is - that I have found particularly important is people's ability to solve problems.
The suicidal state in many ways is defined by an inability to effectively solve problems. And where we can really find success, I think - and we've done some of this work, at least when I was active duty - is teaching leaders, teaching NCOs, teaching commanders how to help their people solve problems very early on; not waiting until it's a crisis, but as soon as a problem is identified, how do you get a solution to that problem so it does not escalate. And you have to just kind of teach people and train them constantly so that they become better and better and better at solving problems. And in many ways, you do reduce the likelihood of suicide then.
David: Interesting. Now, you got a large government grant for research. What can you tell us about the research that you're conducting?
Craig Bryan: Yes, we've got several studies going on now, and we've got some studies looking at treating PTSD amongst active duty service members, and then some studies looking at treating active duty suicidal service members. And basically what we're doing in all of these studies is we're taking treatments that are - we already know they work, and they have been shown to work primarily in civilian populations, and what we're doing now is we're demonstrating that they work within the military as well. Now, of course, most of us who use these treatments know the treatments work within the military, but we have not yet been able to demonstrate that scientifically.
And, importantly, there's a lot of modifications that you have to make to existing treatments to make them work within the military because, as I mentioned before, it's a different mindset, it's a different culture, so you have to modify language. A lot of times you have to kind of understand how the system works. There's a hierarchy; how do you work with commanders and leadership? How do you modify a treatment to respond to, as I mentioned before, that constant change and instability? So you might have an appointment set up with a service member and then their unit gets activated and they have to go do something, and so he can't come into the appointment. Well, how do you make that work within this setting where, in many ways, you almost don't want to hang your hat on what's going to happen too far in the future because it's quite likely to change?
David: You said that in the civilian sector we have effective approaches that we know work. What are those effective approaches? I know you could go on a long time about that, but sort of in brief.
Craig Bryan: Yes. For PTSD there are two treatments that - I mean they are the gold standard; they really rise above the rest. That's prolonged exposure and cognitive processing therapy. And both have long histories. They have been demonstrated again and again and again to be superior to other forms of therapy, both other psychotherapies and other medication treatments. And so, in many ways, for an individual who has PTSD, they're going to a mental health provider for treatment. They should be receiving one of those as the front-line intervention. Those really are the two best treatments.
For suicide, we have several variations of cognitive-behavioral therapies. So kind of the treatment that's sort of received the most scientific support is dialectical behavior therapy, which is, of course, Marsha Linehan's treatment.
David: Yes, I interviewed her on this series, actually.
Craig Bryan: Yes, yes. So she has published several studies from randomized controls trials. Of course, her patients are primarily female and they meet criteria for borderline personality disorder, but one of the primary symptoms and criteria for a diagnosis of bipolar - borderline personality disorders were current suicidal behaviors, and DBT has been found now several times to reduce the likelihood of subsequent suicide attempts by about 50%.
Then another treatment - and the treatment that we're actually testing now for the military - is based on a treatment protocol developed at the University of Pennsylvania with Greg Brown, Amy Wenzel, Aaron Beck, and it's a cognitive therapy protocol. It's a brief 12-session cognitive therapy protocol, and they also found, after 12 sessions of their treatment, subsequent suicide attempts were reduced by about 50%.
David: Well, that's great. I wasn't aware of that. That's good news.
Craig Bryan: Yes, I mean that's a huge difference between the conditions, and in both cases, the comparison - what they were comparing DBT or cognitive therapy to was what's called treatment as usual. So basically it's just whatever is the typical therapy that you might receive if you were to go to an average psychologist, psychiatrist, social worker, LPC - just sort of whatever that typical care is. So it wasn't a placebo condition. You can't do placebo research with suicidal individuals, but what you do is you compare your treatment to what is considered the standard of care, and if you can show that your treatment is better than standard care, then that's sort of the effect that you're trying to demonstrate.
David: And these were able to demonstrate that?
Craig Bryan: Yes. In both cases, like I said, 50% reduction in suicide attempts on average comparing their active treatments to the standard of care.
David: Um-hmm. I noticed on Amazon.com that you've co-authored a book titled Managing Suicide Risk in Primary Care. Who's the intended audience for that book? And what was the main message of it?
Craig Bryan: Yes. Sort of the primary audience, probably those who will find the most important relevance or useful information from that, are mental health providers who are working within primary care clinics. So this is kind of a new direction within the mental health profession is integrating within medical settings. And so we wrote the book with that audience kind of at the forefront of our mind, but we didn't want the book to be that narrow in scope, and so really any mental health professional working in any setting would probably find this book useful.
Because really what we're doing is we're taking interventions from dialectical behavioral therapy, from cognitive therapy, from other CBT trials that have shown some efficacy for reducing suicide risk, and it's sort of now we've got to make these treatments work within a new context where you don't have a lot of time to work with a patient. And so we break down most of the interventions into sort of this is how you do an intervention and make it work. So if any clinician out there is sort of like "I don't really know what to do with a suicidal patient," they can pick up the book, even if they're not working in primary care, and they're going to get very detailed sort of how to do these interventions. And all of them are scientifically supported.
Other audiences who might find it useful are just really any medical professional who's working in primary care or other settings. Emergency departments - there's some applicability there as well because in emergency departments you're trying to make very rapid decisions with patients. And so it's anyone who's interested in sort of what do I do with someone who's thinking about killing themselves, they would find the book useful.
David: Well, that's a great resource to be aware of. I know we have many listeners who are therapists of one sort or another, and so that's a good resource for them to know about. This is probably a good place for us to wind it down. You've been very generous with your time and your information. Dr. Craig Bryan, thanks so much for being my guest on Wise Counsel.
Craig Bryan: Great. Again, thanks for having me.
David: I hope you enjoyed this conversation with Dr. Craig Bryan. If this is a topic of interest to you, I suggest you listen to the March 13, 2009, Wise Counsel interview I did with Dr. Thomas Joiner on his work in suicide; as well as my August 4, 2008, interview with Dr. Edna Foa of the University of Pennsylvania on treating PTSD; and my October 16, 2007, interview with Marsha Linehan on dialectical behavior therapy. If you haven't already heard these interviews, they are excellent supplements to the current one, if I do say so myself.
You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.
If you like Wise Counsel, you might also like Shrink Rap Radio, my other interview podcast series, which is available online at www.shrinkrapradio.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.
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About Craig Bryan, Psy.D.
Dr. Craig J. Bryan, PsyD, is Assistant Professor in the Department of Psychiatry at the University of Texas Health Science Center.
Dr. Bryan received his PsyD in clinical psychology in 2006 from Baylor University, and completed his clinical psychology residency at the Wilford Hall Medical Center, Lackland Air Force Base, TX. He was retained as faculty in the Department of Psychology at Wilford Hall Medical Center, where he was Chief of the Primary Care Psychology Service, as well as the Suicide Prevention Program Manager for Lackland AFB. Dr. Bryan deployed to Joint Base Balad, Iraq, from February to August 2009, where he served as the Director of the Traumatic Brain Injury Clinic at the Air Force Theater Hospital—the primary Level III trauma hospital in Iraq.
Dr. Bryan separated from active duty service shortly after his deployment, and currently researches suicidal behaviors and suicide prevention strategies, and psychological health and resiliency. He is currently the Project Director for a $1.97 million study testing a cognitive behavioral psychotherapy for suicidal service members. He has additionally chaired the American Association of Suicidology’s Primary Care Task Force to develop training curriculum for primary care medical providers in the assessment and management of suicidal patients.
Currently Dr. Bryan is a lead consultant to the U.S. Air Force for psychological health promotion initiatives, and to the U.S. Marine Corps for suicide prevention. He regularly provides training to clinicians and medical professionals about managing suicidal patients, and has dozens of publications in the areas of suicide and military mental health, including the forthcoming book Managing Suicide Risk in Primary Care. For his contributions to primary care behavioral health and military suicide prevention, Dr. Bryan was recognized by the Society for Military Psychology with the Arthur W. Melton Award for Early Career Achievement.