From Practice Wisdom to Evidence-Based Intervention: Developing the Family-Based Crisis Intervention (FBCI) for Suicidal Adolescents
Suicide is the third leading cause of death of youth between the ages of 10 and 24 in the US (CDC, 2009b). Despite an abundance of published conceptual discussions of suicide risk and protective factors, few evidenced-based suicide interventions exist (NREPP, 2012). Only two (Asarnow, Baraff, Berk et al., 2011; Rotheram-Borus, Piacentini, Van Rossem et al., 1999) have been implemented in the emergency department (ED) with suicidal adolescents. Neither intervention yielded reductions in suicidality or hospitalization rates. Noting a need for an ED-based intervention designed to address these two outcomes, the authors utilized social work practice wisdom to develop a single-session family-based crisis intervention (FBCI). In this paper, the authors describe a series of three studies of FBCI to illustrate the evidence-based intervention development process (Pollio, 2006; Sheldon, 2001; Thyer, 2004).
FBCI originated in a large New England teaching hospital after the authors noticed a substantial increase in suicidal adolescents being “boarded” in the ED while waiting for an inpatient psychiatric bed, thereby forgoing much needed psychiatric care. The authors discovered that an ED crisis intervention with these adolescents and families could often reduce suicidality and enhance coping skills in both the teen and parents, allowing many of these patients to return home safely, instead of waiting hours or days for psychiatric hospitalization. First, the authors conducted an open trial of FBCI, in which demographic and clinical characteristics and disposition outcomes from the pilot sample (n=100) were compared to a retrospectively matched comparison group. In the second study, the authors pilot tested a manualized version of FBCI. The third study, a randomized clinical trial comparing patient outcomes between suicidal adolescents who received treatment as usual (TAU) and FBCI commenced in January 2012 and is ongoing.
Results from the initial open trial reveal that patients receiving FBCI were significantly less likely to be admitted to inpatient psychiatric units than a matched retrospective comparison sample (35% vs. 55.3%; p<0.01) and were functioning well on follow-up. Results from the pilot study of the manualized version of FBCI showed comparable results (70% discharged home) as well as clinically significant reductions in suicidality and hopelessness. Outcome measures in the randomized clinical trial were further revised to include several patient-level psychometric measures of adolescent functioning, including family communication and empowerment as well as more system-level outcome measures, including ED recidivism, and additional services obtained.
Too often, social workers are the master clinicians who wait for other disciplines to create and test clinical treatments. The process of developing and testing FBCI shows that social workers can (and should) use their practice knowledge to create and assess interventions with the overall goal of developing a body of social work-inspired evidenced based practice. These studies illustrate how practice wisdom can be utilized to address an unmet need of a vulnerable population. Future directions, including dismantling studies and effectiveness trials, will also be discussed.