WEBVTT

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- Welcome on this rather
sweltering evening.

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Thank you for coming out for this event.

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For those of you who don't know me,

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I'm Kathryn Basham, nice to
see a lot of familiar faces

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and some new faces here in the audience.

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I am one of the co-directors
of the PhD program

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and I've been here quite
a while and glad to see

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some of the students who've
been actively involved

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in our military social work initiatives.

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Those of you may know,
some of you don't know,

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that we are 99 years old as a school

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and next year, we'll celebrate
our 100th anniversary.

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The school was started basically to serve

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veterans of World War I with shell shock.

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And the history is
fascinating to really trace

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what social work students actually did.

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Clinical social work students
were summoned to be educated

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to actually work with this
population who were in Europe,

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in theater at the time,
students were recruited

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to come in the summers, was
considered a very odd plan.

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No other social work program had this plan

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and thus, The Block Plan, so the education

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was primarily in social
work, clinical social work

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'cause it was mental health
orientated, shell shock related.

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And the efforts were trying to
really work with the veterans

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and their families, so
it's an interesting history

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and I'm very pleased to be a
part of this ongoing commitment

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and a number of us here in the audience

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are very involved as well,
so I am delighted to be able

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to present and honored to
present Dr. Lisa Brenner.

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This is one of our, the second

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in our public series of lectures.

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And Dr. Brenner has specialized in working

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with the mental health
issues surrounding veterans

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with a vast research
background and tonight,

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she's particularly going to
focus on traumatic brain injury

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with issues of suicide risk.

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So Dr. Brenner, no, no, no,
no, you have to be introduced.

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(audience laughs)

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Excuse me, a little more detail, come on.

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Okay, she is a board-certified
rehabilitation psychologist

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and a professor of
physical medicine in rehab

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at the University of Colorado
Anschutz School of Medicine

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and the director of the Rocky
Mountain Mental Illness,

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Research, Education and Clinical Center.

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She's also a fellow of
the American Psychological

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Association Division 22
Rehabilitation Psychology.

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Her primary area of research interest

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is traumatic brain injury,
comorbid psychiatric conditions,

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and negative psychiatric
outcomes, including suicide.

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She serves as the
research division director

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for the American
Association of Suicidology

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and has reviewed
publications, participates

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on national advisory boards,
and is currently co-authoring

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a book regarding
neuro-disability and suicide.

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So please join me in
welcoming Dr. Brenner.

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(audience applauding)

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- Thank you so much, I think I have,

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is this working now,
where's my good friend?

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Thank you, okay, great, I should tell you

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before I get started
that I came to this work

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in a very unusual work in that I spent,

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I actually went to a very
psycho-dynamically oriented

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school, I was trained
in psycho-dynamic theory

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at a place called The
Wright Institute in Berkeley

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and I went to Brandeis before that so,

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and at Brandeis, I majored in
psychology and women's studies

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so I thought that my life
would like very, very different

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than it does, I didn't think
that I would be working

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with mostly men and veterans,
that wasn't the career path

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I had in mind, I also
didn't think I'd be working

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with more physical manifestations
and physical illness.

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For me, really, it all
changed when I was doing

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my training and I was doing my training

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at the Denver VA and I
realized that this was,

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there was some avenues
that I'd never thought

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about explored and so
my trajectory changed

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and I then focused on doing
very specific inpatient work

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with folks who had lots
of physical conditions

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and then about 10 years
later, somebody said,

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"Hey, do you wanna try to do research?"

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And I was like, okay,
I didn't really think

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about doing that, I'd
done a lot of training

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and so I got a change about,
it was about 10 years ago

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to start doing research and
that really worked out for me.

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So I guess all of you who
think you know what I wanna do

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or think about you know the
path that you're gonna take

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and you have it all set,
I would just say be open.

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Really amazing things
can happen that you would

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never anticipate and I
would certainly say that

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about my career in the VA,
I've had many, many careers

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in the VA and it's been
a great place for me.

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So that's not really what
I'm supposed to be talking

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about today but I felt
inspired to say that

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just so you know where I'm
coming from in talking about this

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today, I should also say
that everything I say today

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is all me, it's not the
VA, so if I say anything

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particularly crazy today,
that's definitely not the VA,

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that's me, okay, so in my research,

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and you'll see, I'm gonna show you lots

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of different methods, qualitative methods,

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more epidemiologic methods,
interventional methods,

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this is a quote from a veteran.

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We were doing a qualitative
study, I'll talk

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a little bit more about it
later, and the veteran said,

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"I think it took a while before I realized

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"and then when I started
thinking about things

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"and realizing that I
was gonna be like this,"

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like this is with a big ole brain injury,

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"for the rest of my life,
it gives me a really down

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"feeling and it makes me
think, why should I be around

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"like this for the rest of my life?"

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And this is very common,
particularly for folks

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who have moderate to
severe TBI and I'll talk

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more about, if you don't know
what moderate to severe TBI

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is, you will be the end of this lecture.

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But really how do we help
people create meaning?

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And one thing you'll hear
over and over again tonight

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is that folks in mental health often think

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brain injury is not my
purview, brain injury's

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a physical health condition,
I need to refer out

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for brain injury and if you're
not gonna hear anything else

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tonight and this is like
the end, the punchline

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right now is actually brain
injury is your purview.

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And we actually need
it to be your purview,

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not just for military veterans
but actually everybody

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because this is all happening
in the brain, right?

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I know you all probably
feel pretty comfortable

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with thinking about
major depressive disorder

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or post-traumatic stress
disorder, all that's originating

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also in the brain, these are
all brain-based conditions

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and you actually have many
of the skills necessary

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to work the best with folks
who have brain injuries

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so I hope that that will be
something you are convinced

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about over the next time we're talking.

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The other thing I would say is
if you wanna be a researcher,

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pick something that nobody's doing.

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(audience chuckles)
Right?

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Then you can be really famous, right?

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Because nobody else is
doing it, so you see

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this PubMed, TBI and suicide.

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And you can see that
this has become an area

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of big interest, not just
with military populations

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but with all populations
and this is for a number

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of different reasons and you can see look

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at these tiny little numbers
over there, zero to 20, right?

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If you do this same kind of
search with major depression

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and suicide, it'll be in the thousands.

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It's pretty hard to
make a name for yourself

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if it's in the thousands,
so try to pick something

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that's an intersection of things
that people are looking at

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but nobody's look at
really specifically yet.

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And that's how you get to,
and then all you have to do

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is bring this whole school of thought here

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and this whole school
of thought here together

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and people think, holy
smokes, you're really smart.

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And actually what you're
doing is just bridging, okay?

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All right, so this is when
I started doing research,

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right about here, and it's
actually really gratifying to me

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to see that lots and lots
of people are starting

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to do this work now 'cause
really what you're trying

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to do is plant the seed and
that other people need to do it.

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Okay, so here we're gonna play some games.

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It's gonna be participatory
today, okay, so this is,

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if you're in the military
and you know this,

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do not answer (laughs).

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How many people do you
think have been deployed

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in Iraq and Afghanistan since 2001?

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How many?

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- 100,000?
- 100,000.

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Higher or lower?

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- Higher.
- Higher, okay, what?

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- [Man] Three million?

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- Three million, do people
think three million,

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higher or lower?

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- [Audience] Lower.

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- Lower, 300,000.

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- [Woman] (faint speaking) higher.

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- Okay, three million and
300,000, that's a lot.

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(audience laughs)

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What, come on, higher than 300,000.

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- 600,000?
- 600,000.

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- [Woman] 1.5.

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- 1.5 million.

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Okay.

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Our three million was right.

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- [Woman] Wow.

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- Okay, so the interesting thing

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is that these three million,
these folks live in communities

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that maybe you don't intersect with.

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These folks, many of them have
been deployed multiple times

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and, of course, this is
2.7 million individuals

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but each of these individuals
has family members,

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has children, has coworkers,
and so if you think

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about all the people this
has touched, it's much bigger

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than that, but it may be a
community that you have nothing

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to do with and there
are certain communities

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where everybody is in it,
right, or if you work in the VA,

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you're in this all the time.

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I always try to think this
is going on right now still.

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Unfortunately, I'm still saying that.

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I've been saying that for a long time.

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Soldiers were killed
just this weekend, right,

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in Afghanistan so this is still happening.

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It may be for a number of
reasons easy not to have

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in the forefront of our minds
but it is still happening.

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Okay, I have some slides,
I have a lot of numbers.

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I'm really sorry but I did want to share

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some of this with you and I
think this is really good data

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to start to think about what's out there.

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What you can see is on
the far side over there.

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You've got years, and this
is defense casualty data

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and the wars started in
2001 in Iraq, I'm sorry,

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in Afghanistan, and then 2003,
sorry, I'm saying that right,

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in Afghanistan and Iraq,
okay, so then you see

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this is first year, total deaths
and you see hostile action

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is 12, and then you self
inflicted, 153, okay?

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But what you start to notice down here.

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Oh, this is shorter than
me, okay, see down here?

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what you start to see is 346

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but what, 302, so this number is almost,

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and there were further
years where this number

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actually was equal to or higher

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than that number and that,
for many good reasons

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starting getting people's
attention, what was going on

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with this cohort that those numbers

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were flipping in those ways.

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This is just another way
of looking at the data

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and I think a good indication
of why it's important

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to look more closely at data.

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This is the DoD suicide rate per year.

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This is in numbers of deaths
and this is per 100,000.

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If you just look at
these, you might think,

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okay, there's maybe a
little bit of a problem.

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But if you break out the
right data, you can see

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the problem is really much
greater for different cohorts.

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This is by service so this is Army.

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And so much higher rates in
the Army than other services.

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Okay, and you might miss
that too if you're looking

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at the per 100,000 also,
so just different ways

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that you can look at data
that really doesn't give you

242
00:11:41.935 --> 00:11:43.436
the story you need, I would say this

243
00:11:43.436 --> 00:11:46.134
is the most important part over here,

244
00:11:46.134 --> 00:11:48.577
what's happening with folks in the Army

245
00:11:48.577 --> 00:11:52.148
who really are deployed and on the ground

246
00:11:52.148 --> 00:11:56.315
more than other folks that
is contributing or not.

247
00:11:57.869 --> 00:11:59.465
So then the other thing
I always like to do,

248
00:11:59.465 --> 00:12:03.042
I always try to fight context
before we get really into it

249
00:12:03.042 --> 00:12:07.162
and so if you think
about that 2.7 million,

250
00:12:07.162 --> 00:12:10.163
all those individuals actually
at this point, this was,

251
00:12:10.163 --> 00:12:12.603
it's actually very hard
to get data in real time

252
00:12:12.603 --> 00:12:15.568
but there's one million,
probably 1.2 million,

253
00:12:15.568 --> 00:12:18.880
1.5 million, probably more now,
individuals who are eligible

254
00:12:18.880 --> 00:12:23.453
for VA care now, so every
time you hear a story

255
00:12:23.453 --> 00:12:26.499
about the VA on the news,
this is the Lisa part

256
00:12:26.499 --> 00:12:29.127
talking not the VA talking,
every time you think

257
00:12:29.127 --> 00:12:31.447
about the VA on the news, I'm sure,

258
00:12:31.447 --> 00:12:33.486
who's heard the VA on the news?

259
00:12:33.486 --> 00:12:36.286
Yes, of course, I want you to think

260
00:12:36.286 --> 00:12:39.514
about a healthcare system
integrating 1.5 million

261
00:12:39.514 --> 00:12:42.484
new people, okay, 'cause
that's a very different way

262
00:12:42.484 --> 00:12:46.297
of thinking about it, and not
only 1.5 million new people

263
00:12:46.297 --> 00:12:49.188
but what you have here and
this number doesn't look huge,

264
00:12:49.188 --> 00:12:52.458
the 12.3 but we did have 12.3%
women when I started working

265
00:12:52.458 --> 00:12:56.163
at the VA, right, so
these individuals need

266
00:12:56.163 --> 00:12:58.846
very different kind of healthcare
and we also didn't have

267
00:12:58.846 --> 00:13:02.848
this when I started working
at the VA, much younger folks

268
00:13:02.848 --> 00:13:06.502
with much younger
health-related conditions.

269
00:13:06.502 --> 00:13:09.833
There's another thing you'll
notice, mostly enlisted,

270
00:13:09.833 --> 00:13:13.603
so folks that may have less
resources than officers

271
00:13:13.603 --> 00:13:17.946
and again, mostly Army, I mean
active duty and then Army.

272
00:13:17.946 --> 00:13:20.688
That won't surprise you
with the Army, right?

273
00:13:20.688 --> 00:13:24.766
Okay, and then here, just to highlight,

274
00:13:24.766 --> 00:13:27.119
this is what people are
actually getting care for,

275
00:13:27.119 --> 00:13:29.861
cumulatively, and you'll see these numbers

276
00:13:29.861 --> 00:13:32.412
don't add up to 100,
but the bigger numbers

277
00:13:32.412 --> 00:13:34.965
are mental disorders and
disease of the nervous system

278
00:13:34.965 --> 00:13:38.668
and sense organs, brain injury,
mental health conditions.

279
00:13:38.668 --> 00:13:41.205
That's what people are getting care for,

280
00:13:41.205 --> 00:13:43.754
amongst all other things.

281
00:13:43.754 --> 00:13:45.628
I was talking to somebody
earlier today, we're also seeing

282
00:13:45.628 --> 00:13:48.638
lots of interesting conditions
amongst these cohorts,

283
00:13:48.638 --> 00:13:51.321
things that are unusual
in younger veterans,

284
00:13:51.321 --> 00:13:54.120
things like sleep apnea,
much higher rates.

285
00:13:54.120 --> 00:13:56.428
GERD actually and GI
problems, I've been reviewing

286
00:13:56.428 --> 00:13:58.578
a lot of charts lately and
almost all the veterans

287
00:13:58.578 --> 00:14:00.312
I've been seeing are on medication

288
00:14:00.312 --> 00:14:03.510
for stomach-related problems,
so things that you just

289
00:14:03.510 --> 00:14:06.029
wouldn't expect and
that's a different lecture

290
00:14:06.029 --> 00:14:09.969
for a different day, okay,
so now we're gonna get

291
00:14:09.969 --> 00:14:12.882
more into the suicide and TBI thing.

292
00:14:12.882 --> 00:14:15.128
Before we do that, I think
it's really important

293
00:14:15.128 --> 00:14:16.926
to make sure that we're on the same page

294
00:14:16.926 --> 00:14:19.652
about what do these variables mean, right?

295
00:14:19.652 --> 00:14:23.505
I think of them as variables,
behaviors, what do they mean?

296
00:14:23.505 --> 00:14:26.389
And so when I started doing research,

297
00:14:26.389 --> 00:14:29.471
I realized that there was
no classification system

298
00:14:29.471 --> 00:14:33.169
for suicide, there was no
common language for suicide

299
00:14:33.169 --> 00:14:35.602
and that seems kinda crazy, right?

300
00:14:35.602 --> 00:14:37.440
There was no common language for suicide

301
00:14:37.440 --> 00:14:41.045
and suicide-related behavior,
which is a really big problem

302
00:14:41.045 --> 00:14:43.377
for a number of reasons, so clinically,

303
00:14:43.377 --> 00:14:46.713
this is the participatory
part, you all can help

304
00:14:46.713 --> 00:14:49.134
'cause I can see you all.

305
00:14:49.134 --> 00:14:51.760
Clinically, why would it be a
problem if I think a suicide

306
00:14:51.760 --> 00:14:54.037
attempt is different than
somebody on an inpatient unit?

307
00:14:54.037 --> 00:14:56.616
So I'm doing intake and
somebody in the inpatient unit

308
00:14:56.616 --> 00:14:59.022
thinks something, suicide
attempt defines it differently.

309
00:14:59.022 --> 00:15:01.355
Why would that be a problem?

310
00:15:07.484 --> 00:15:09.474
I know you people at Smith
are way smarter than this.

311
00:15:09.474 --> 00:15:11.614
(audience laughs)

312
00:15:11.614 --> 00:15:13.186
Why would it be a problem if
I have a different definition

313
00:15:13.186 --> 00:15:14.833
or a different understanding
of a term than somebody

314
00:15:14.833 --> 00:15:17.930
that works in the same hospital that I do?

315
00:15:17.930 --> 00:15:19.513
Yep, yep, what was?

316
00:15:20.972 --> 00:15:23.150
(faint speaking)

317
00:15:23.150 --> 00:15:26.322
That's a different problem,
that's a policy problem.

318
00:15:26.322 --> 00:15:29.639
So on a person level, so I'm
doing the intake diligently

319
00:15:29.639 --> 00:15:31.838
in the ED, I transfer
the person and the person

320
00:15:31.838 --> 00:15:34.283
on the inpatient unit has
a different definition.

321
00:15:34.283 --> 00:15:36.275
We are not treatment planning,
we are not assessing risk

322
00:15:36.275 --> 00:15:39.492
in the same way, that's a big problem.

323
00:15:39.492 --> 00:15:42.409
Okay, how is it a research problem?

324
00:15:43.762 --> 00:15:45.321
- [Woman] There's no way to quantify.

325
00:15:45.321 --> 00:15:47.422
- There's no way to quantify.
- Separate the data.

326
00:15:47.422 --> 00:15:49.597
There's no way to quantify
and separate the data

327
00:15:49.597 --> 00:15:52.728
so if I'm quantifying
and separating the data,

328
00:15:52.728 --> 00:15:57.219
if I'm not operationalizing
it in the same way, right?

329
00:15:57.219 --> 00:15:59.298
And then I'm trying to
pull together research,

330
00:15:59.298 --> 00:16:02.435
I may be lumping where
I shouldn't be, right?

331
00:16:02.435 --> 00:16:04.793
So if I'm trying to think across studies

332
00:16:04.793 --> 00:16:07.793
and my excellent study
and your excellent study

333
00:16:07.793 --> 00:16:10.040
your excellent study, we're
all defining suicide attempts

334
00:16:10.040 --> 00:16:13.004
in different ways, we can't lump.

335
00:16:13.004 --> 00:16:15.507
And then that becomes
a big problem, right?

336
00:16:15.507 --> 00:16:18.599
Because we can't get bodies
of research together, okay,

337
00:16:18.599 --> 00:16:21.349
and then our policy
problem, how much resources

338
00:16:21.349 --> 00:16:23.355
should be put towards something if we

339
00:16:23.355 --> 00:16:25.408
aren't really counting it correctly?

340
00:16:25.408 --> 00:16:27.870
So three big problems, it
doesn't matter what you're doing.

341
00:16:27.870 --> 00:16:30.477
This is a problem, so we
thought, okay, we're gonna work

342
00:16:30.477 --> 00:16:33.127
with the CDC and come up with something

343
00:16:33.127 --> 00:16:36.041
that actually helps define this.

344
00:16:36.041 --> 00:16:37.668
And this is something we created.

345
00:16:37.668 --> 00:16:38.801
I'm not gonna go too far into this today.

346
00:16:38.801 --> 00:16:41.108
I mostly just highlighted
here, this is on our website.

347
00:16:41.108 --> 00:16:42.580
See what you can do to find this.

348
00:16:42.580 --> 00:16:43.835
Do you see I put a little clue down there,

349
00:16:43.835 --> 00:16:46.548
how you can find stuff,
all you do is google.

350
00:16:46.548 --> 00:16:48.816
I know you know how to do
that, Rocky Mountain MIRECC

351
00:16:48.816 --> 00:16:51.630
and this stuff I'm gonna show
you today is on there, okay.

352
00:16:51.630 --> 00:16:54.020
And this is the classification system.

353
00:16:54.020 --> 00:16:56.584
There is definitions, there is a tool.

354
00:16:56.584 --> 00:16:59.266
There's also an online decision tree

355
00:16:59.266 --> 00:17:02.783
and this has been implemented
in the VA and DoD on whole.

356
00:17:02.783 --> 00:17:05.784
This is what it looks like,
ta-da, I'm not gonna show you

357
00:17:05.784 --> 00:17:08.524
the clinical tool today
but the clinical tool

358
00:17:08.524 --> 00:17:10.478
is actually pretty good, all you do is ask

359
00:17:10.478 --> 00:17:13.202
two or three questions and it
gets you to the right term.

360
00:17:13.202 --> 00:17:16.549
And there's the online version
and the not online version.

361
00:17:16.549 --> 00:17:18.806
The way this is organized,
it's by thoughts

362
00:17:18.806 --> 00:17:20.570
and then behaviors.

363
00:17:20.570 --> 00:17:22.487
Okay, what's a thought?

364
00:17:25.222 --> 00:17:26.380
- [Woman] I'm hungry!

365
00:17:26.380 --> 00:17:28.626
- I'm hungry, great, so it's
something you think, right?

366
00:17:28.626 --> 00:17:31.123
Thoughts and then a behavior is what?

367
00:17:31.123 --> 00:17:34.775
Something you do, right, so
in this classification system,

368
00:17:34.775 --> 00:17:37.942
behaviors trump thoughts, right, okay.

369
00:17:38.838 --> 00:17:41.782
And what you can do is you,
with these few questions,

370
00:17:41.782 --> 00:17:44.056
I'm not gonna show this
tool today, you can get

371
00:17:44.056 --> 00:17:47.756
to the right term, and that means that I,

372
00:17:47.756 --> 00:17:49.828
like the person on the inpatient unit,

373
00:17:49.828 --> 00:17:52.475
and I can have the same idea,
okay, when we're working

374
00:17:52.475 --> 00:17:55.720
with the person or if I'm
doing research or policy.

375
00:17:55.720 --> 00:17:57.422
The other thing that has really different

376
00:17:57.422 --> 00:17:59.663
than we had done before, had been existed

377
00:17:59.663 --> 00:18:02.411
before is this idea of undetermined.

378
00:18:02.411 --> 00:18:04.242
Undetermined, in my
mind, means I don't have

379
00:18:04.242 --> 00:18:07.186
enough information, okay,
as a clinician, I don't have

380
00:18:07.186 --> 00:18:10.323
enough information yet,
so I need to keep working

381
00:18:10.323 --> 00:18:12.518
to get enough information
to figure out if this

382
00:18:12.518 --> 00:18:15.625
is a suicide attempt or not
or suicidal behavior or not.

383
00:18:15.625 --> 00:18:18.008
So I think of undetermined
as a placeholder.

384
00:18:18.008 --> 00:18:20.882
The other thing that's on
here is preparatory behavior.

385
00:18:20.882 --> 00:18:23.569
Preparatory behavior is
behavior that is leading

386
00:18:23.569 --> 00:18:27.152
towards a suicidal act
but not yet the act.

387
00:18:28.298 --> 00:18:30.553
Now, I can, there's a different
lecture I could give today

388
00:18:30.553 --> 00:18:32.758
on this, I'm not gonna give that lecture

389
00:18:32.758 --> 00:18:35.935
but if you go to this website
you can watch this lecture.

390
00:18:35.935 --> 00:18:38.016
Okay, and so this is
something you all can do

391
00:18:38.016 --> 00:18:40.051
and I will tell you if
you do this and use this

392
00:18:40.051 --> 00:18:42.728
and use this in your charting,
you will be so far ahead

393
00:18:42.728 --> 00:18:46.396
of the game in terms of your
clinical work, okay, all right,

394
00:18:46.396 --> 00:18:48.223
so we all know what we're
talking about with suicide

395
00:18:48.223 --> 00:18:51.545
and suicide attempts 'cause
we have the same ideas now,

396
00:18:51.545 --> 00:18:55.554
the same terms, okay, so
let's talk about brain injury.

397
00:18:55.554 --> 00:18:58.333
So much confusion about
what brain injury is,

398
00:18:58.333 --> 00:18:59.833
so much confusion.

399
00:19:02.784 --> 00:19:05.211
So a brain injury is
actually, first of all,

400
00:19:05.211 --> 00:19:08.775
a historical event, it's
something that already happened.

401
00:19:08.775 --> 00:19:10.623
It's like a broken ankle, it's something

402
00:19:10.623 --> 00:19:12.693
that already happened, and there's

403
00:19:12.693 --> 00:19:15.111
only two really easy parts to it.

404
00:19:15.111 --> 00:19:18.883
You have an injury event and
an alteration in consciousness.

405
00:19:18.883 --> 00:19:21.676
That's it, right, that's a brain injury.

406
00:19:21.676 --> 00:19:23.963
Injury event, alteration in consciousness.

407
00:19:23.963 --> 00:19:27.169
Now the hard part can be the
alteration in consciousness.

408
00:19:27.169 --> 00:19:29.075
The alteration in consciousness can range

409
00:19:29.075 --> 00:19:31.288
from I had my bell rung to I'm in

410
00:19:31.288 --> 00:19:34.544
a persistent vegetative
state, and that's what creates

411
00:19:34.544 --> 00:19:38.711
all the confusion, right,
okay, and TBIs can result

412
00:19:39.834 --> 00:19:43.295
in long- or short-term problems.

413
00:19:43.295 --> 00:19:47.147
Who gets more brain
injuries, guys or gals?

414
00:19:47.147 --> 00:19:48.980
Guys, guys, okay, why?

415
00:19:52.115 --> 00:19:57.000
That's right, it's not
sports, it's crazy business.

416
00:19:57.000 --> 00:20:01.421
Guys more than gals age
ranges for brain injury,

417
00:20:01.421 --> 00:20:03.710
there's three.
- 13 to 23.

418
00:20:03.710 --> 00:20:06.127
- Yeah, 15 to, like 15 to 24.

419
00:20:09.285 --> 00:20:10.782
What else?

420
00:20:10.782 --> 00:20:12.718
When do I get all the phone
calls about oh my god,

421
00:20:12.718 --> 00:20:17.043
my kid is learning how to
walk and they got a goose egg?

422
00:20:17.043 --> 00:20:19.635
So little kids, and
what's the third group?

423
00:20:19.635 --> 00:20:20.500
- [Women] Elders.

424
00:20:20.500 --> 00:20:23.540
- Elders, okay, how do older
people get brain injuries?

425
00:20:23.540 --> 00:20:24.373
- [Audience] Falls.

426
00:20:24.373 --> 00:20:26.263
- Falls, and we already
said how younger people

427
00:20:26.263 --> 00:20:30.048
get brain injuries, crazy business, okay.

428
00:20:30.048 --> 00:20:33.578
80% of the brain injuries
that occur are mild, okay?

429
00:20:33.578 --> 00:20:35.385
And when I say mild, moderate, and severe,

430
00:20:35.385 --> 00:20:38.271
I don't mean how bad was your headache?

431
00:20:38.271 --> 00:20:39.730
How bad are your symptoms after?

432
00:20:39.730 --> 00:20:42.319
I mean how bad, how
serious was the alteration

433
00:20:42.319 --> 00:20:46.412
in consciousness, okay,
and so mild, you can see

434
00:20:46.412 --> 00:20:48.928
I'm not not gonna go so, so far into this.

435
00:20:48.928 --> 00:20:53.662
Mild is you don't have a
significant loss of consciousness.

436
00:20:53.662 --> 00:20:56.622
It's less than 30 minutes,
mild TBI is the same

437
00:20:56.622 --> 00:20:58.664
as concussion, I won't
make you raise your hand

438
00:20:58.664 --> 00:21:00.791
if you've ever had a
concussion, it's many of you,

439
00:21:00.791 --> 00:21:04.895
I already know, okay, lots
of people get concussions.

440
00:21:04.895 --> 00:21:07.568
It's fine, most people
have multiple concussions

441
00:21:07.568 --> 00:21:09.558
in them and they will be fine.

442
00:21:09.558 --> 00:21:10.975
The part of the problem is we don't know

443
00:21:10.975 --> 00:21:13.375
what the number concussions is per person

444
00:21:13.375 --> 00:21:15.592
so maybe someday it'll be really fancy.

445
00:21:15.592 --> 00:21:17.328
I can have a blood test and they'll say,

446
00:21:17.328 --> 00:21:19.863
oh, Lisa, you could be
a professional boxer

447
00:21:19.863 --> 00:21:21.961
'cause could you get 100 TBIs, mild TBIs

448
00:21:21.961 --> 00:21:24.076
and you'd be good to go
but maybe somebody else

449
00:21:24.076 --> 00:21:28.050
over here can only get two,
but we don't know that yet.

450
00:21:28.050 --> 00:21:30.322
Does that make sense,
like a lifetime load?

451
00:21:30.322 --> 00:21:32.465
Okay, that would be genetics,
that would be a whole bunch

452
00:21:32.465 --> 00:21:34.438
of things that would contribute to that,

453
00:21:34.438 --> 00:21:36.019
but right now, we don't know that.

454
00:21:36.019 --> 00:21:38.498
So we're doing a lot of
guessing around sports.

455
00:21:38.498 --> 00:21:40.302
I know you've all seen
this around sports, right?

456
00:21:40.302 --> 00:21:41.899
Like when's too many, when
should you quit playing,

457
00:21:41.899 --> 00:21:45.149
all that stuff, that's a mild TBI.

458
00:21:45.149 --> 00:21:48.845
Okay, moderate and severe, I
think of mild as by itself,

459
00:21:48.845 --> 00:21:51.663
moderate severe goes together
more significant loss

460
00:21:51.663 --> 00:21:55.830
of consciousness, more expected
long-term symptoms, okay?

461
00:21:56.712 --> 00:22:01.527
And for mild, you can't
have any positive imaging.

462
00:22:01.527 --> 00:22:04.135
When I say positive
imaging here, I'm talking

463
00:22:04.135 --> 00:22:05.882
about a CAT scan or MRI.

464
00:22:05.882 --> 00:22:07.633
I'm not talking about super fancy imaging

465
00:22:07.633 --> 00:22:09.382
that you can pay a lot of money
for that doesn't really mean

466
00:22:09.382 --> 00:22:12.841
anything, so I don't
know if you've all seen

467
00:22:12.841 --> 00:22:14.732
that there's fancy
places you can go and get

468
00:22:14.732 --> 00:22:17.101
really pretty pictures taken
if you've had a brain injury.

469
00:22:17.101 --> 00:22:18.782
Do people know what I'm talking about?

470
00:22:18.782 --> 00:22:20.938
Like SPECT scans or PET scans?

471
00:22:20.938 --> 00:22:22.532
I won't anyway the names of companies.

472
00:22:22.532 --> 00:22:24.721
Somebody's making lots of money off this,

473
00:22:24.721 --> 00:22:27.737
also lots of money from people
who don't have a lot of money

474
00:22:27.737 --> 00:22:31.870
to pay for these, okay, and
they are really amazing pictures

475
00:22:31.870 --> 00:22:33.448
and they are amazing for research.

476
00:22:33.448 --> 00:22:37.053
We actually don't know how to
interpret the pictures yet.

477
00:22:37.053 --> 00:22:41.932
So you will get the report
and it says beautiful picture,

478
00:22:41.932 --> 00:22:44.698
could be brain injury, could be ADHD,

479
00:22:44.698 --> 00:22:47.350
could be bipolar disorder, I'm like that's

480
00:22:47.350 --> 00:22:50.964
not particularly helpful
so I would say right now

481
00:22:50.964 --> 00:22:53.025
if you could discourage
people from getting those

482
00:22:53.025 --> 00:22:55.620
really pretty pictures,
it's like 3,000 bucks,

483
00:22:55.620 --> 00:22:57.974
I would do that, okay,
so right now we know

484
00:22:57.974 --> 00:23:00.274
how to interpret CAT scans and MRIs.

485
00:23:00.274 --> 00:23:02.713
If you have any imaging
on CAT scans or MRIs,

486
00:23:02.713 --> 00:23:05.885
that's not a mild TBI anymore.

487
00:23:05.885 --> 00:23:09.326
But really 80% of TBIs are mild.

488
00:23:09.326 --> 00:23:14.026
And most people go on to have
symptoms, like worst headache

489
00:23:14.026 --> 00:23:17.992
of their life with mild
TBI and then they're fine.

490
00:23:17.992 --> 00:23:21.805
Most individuals return to
baseline functioning in a year.

491
00:23:21.805 --> 00:23:24.720
If we think about common
mild TBI symptoms,

492
00:23:24.720 --> 00:23:26.707
we break it into thinking and remembering

493
00:23:26.707 --> 00:23:30.377
physical symptoms,
emotional mood, and sleep.

494
00:23:30.377 --> 00:23:33.003
Now part of the challenge
with these symptoms,

495
00:23:33.003 --> 00:23:35.555
these are really post-concussive symptoms,

496
00:23:35.555 --> 00:23:38.978
is they are completely nonspecific, right?

497
00:23:38.978 --> 00:23:42.279
So we're gonna play another
game, you have to play.

498
00:23:42.279 --> 00:23:44.215
I'll play too, I'm
gonna start reading them

499
00:23:44.215 --> 00:23:45.547
and I want you to raise
your hand if you had one

500
00:23:45.547 --> 00:23:48.880
in the past week, okay, ready, headache?

501
00:23:50.134 --> 00:23:54.069
Dizziness, irritability,
trouble falling asleep?

502
00:23:54.069 --> 00:23:55.998
Oh, irritability, it was like whoa!

503
00:23:55.998 --> 00:23:57.565
The heat today was like a
winner, everybody's like,

504
00:23:57.565 --> 00:24:00.060
I'm really irritable, okay,
right, so everybody's got

505
00:24:00.060 --> 00:24:02.815
their hand up, and then I
would say to you, if you had

506
00:24:02.815 --> 00:24:05.466
a brain injury, keep your
hand up, everybody else

507
00:24:05.466 --> 00:24:07.309
put their hand down, everybody
would put their hands down.

508
00:24:07.309 --> 00:24:09.667
The problem is all of these
are completely non-specific.

509
00:24:09.667 --> 00:24:14.614
In past week, right, and so
using symptoms to diagnose

510
00:24:14.614 --> 00:24:18.614
brain injury, particularly
mild TBI, is a no-no.

511
00:24:19.776 --> 00:24:22.575
We can talk about a different
day, different lecture

512
00:24:22.575 --> 00:24:24.532
why these are really common symptoms

513
00:24:24.532 --> 00:24:26.821
that are the same symptoms
that you have when you have

514
00:24:26.821 --> 00:24:29.171
the flu or the cold and
it's probably related

515
00:24:29.171 --> 00:24:31.544
to inflammation but that's
a neurobiology lecture

516
00:24:31.544 --> 00:24:35.015
for different day, so
don't use the symptoms

517
00:24:35.015 --> 00:24:36.848
to make the diagnosis.

518
00:24:38.015 --> 00:24:40.333
Okay, so this is data that
we collected at Fort Carson

519
00:24:40.333 --> 00:24:42.809
sometime ago and what we found,

520
00:24:42.809 --> 00:24:44.796
headache is usually
what people talk about.

521
00:24:44.796 --> 00:24:46.495
I had the worst headache of
my life, then it went away,

522
00:24:46.495 --> 00:24:49.240
so and what we did is we said,
okay, which of these symptoms

523
00:24:49.240 --> 00:24:51.476
did you have at the time you were injured

524
00:24:51.476 --> 00:24:54.608
and which did you have post
deployment when you came back?

525
00:24:54.608 --> 00:24:56.687
You can see these nice
decreases of headache,

526
00:24:56.687 --> 00:24:59.275
dizziness, balance problems,
but not so much here and here,

527
00:24:59.275 --> 00:25:02.512
irritability, memory,
so then we said, okay,

528
00:25:02.512 --> 00:25:05.128
well, this is kinda not so
good, let's look at the data

529
00:25:05.128 --> 00:25:07.260
again a different way and we said, okay,

530
00:25:07.260 --> 00:25:10.758
which of these symptoms
did you have at the time

531
00:25:10.758 --> 00:25:14.072
of the injury and which were
new onset post deployment?

532
00:25:14.072 --> 00:25:17.373
Okay, and what you had is
see these big red blocks,

533
00:25:17.373 --> 00:25:20.344
these were really post-deployment symptoms

534
00:25:20.344 --> 00:25:23.259
and what we were having
was TBI symptoms going down

535
00:25:23.259 --> 00:25:26.455
and PTSD symptoms going
up, and so what you see

536
00:25:26.455 --> 00:25:30.189
is this overlap, it could
look like it's weird

537
00:25:30.189 --> 00:25:32.015
or it could look like it's
two conditions overlaying

538
00:25:32.015 --> 00:25:34.751
on each other, and if
you've ever worked at the VA

539
00:25:34.751 --> 00:25:37.774
or the DoD, this is
really what it looks like.

540
00:25:37.774 --> 00:25:40.125
So I have veterans come into my office

541
00:25:40.125 --> 00:25:44.379
and they say, "I have some
problems with attention.

542
00:25:44.379 --> 00:25:47.315
"I have depression, I'm
kinda irritable, I'm anxious,

543
00:25:47.315 --> 00:25:48.706
"and I've got chromic
pain, which of my symptoms

544
00:25:48.706 --> 00:25:51.598
"are related to TBI,
which are related PTSD

545
00:25:51.598 --> 00:25:53.417
"and which are something else?"

546
00:25:53.417 --> 00:25:56.099
And you know what I say to them?

547
00:25:56.099 --> 00:25:59.716
I say I don't know 'cause that's
actually the honest answer.

548
00:25:59.716 --> 00:26:03.090
I actually have no idea,
and I don't actually think

549
00:26:03.090 --> 00:26:06.137
of people like that, I think
of these as all happening

550
00:26:06.137 --> 00:26:09.191
in the brain, and it's even
really more complicated

551
00:26:09.191 --> 00:26:13.167
than this, we did timelines,
qualitative data timelines

552
00:26:13.167 --> 00:26:17.382
of folks from Fort
Carson and so here's one

553
00:26:17.382 --> 00:26:19.937
of the timelines, this veteran deployed.

554
00:26:19.937 --> 00:26:22.317
They were exposed to a traumatic stressor.

555
00:26:22.317 --> 00:26:25.916
They sustained a TBI and they
had post-concussive symptoms.

556
00:26:25.916 --> 00:26:27.480
They returned to the U.S.,
they were still having

557
00:26:27.480 --> 00:26:31.634
mTBI-related symptoms, they
were diagnosed with PTSD

558
00:26:31.634 --> 00:26:36.609
and they received medication
and then they redeploy.

559
00:26:36.609 --> 00:26:38.581
So take out the suicide attempt,
this was did have a suicide

560
00:26:38.581 --> 00:26:43.416
but if I take this off, and
then have three deployments,

561
00:26:43.416 --> 00:26:46.297
I don't see how I can
parse out these symptoms

562
00:26:46.297 --> 00:26:47.938
and I'm not even sure
that's a useful task,

563
00:26:47.938 --> 00:26:50.467
although we did spend a lot
of time in the VA and DoD

564
00:26:50.467 --> 00:26:55.189
trying to parse TBI or PTSD
and there's many reasons

565
00:26:55.189 --> 00:26:59.654
for that, not to mention,
not the least of which

566
00:26:59.654 --> 00:27:02.593
is the way that our
care systems are set up,

567
00:27:02.593 --> 00:27:06.420
TBI and PTSD don't live in
the same system of care.

568
00:27:06.420 --> 00:27:08.314
And that's not just the VA's issue.

569
00:27:08.314 --> 00:27:10.002
That's actually everybody (chuckles).

570
00:27:10.002 --> 00:27:13.209
Mental health is not the
same as neurology or rehab.

571
00:27:13.209 --> 00:27:15.719
And to help those providers
actually start to work together,

572
00:27:15.719 --> 00:27:18.851
that's why we need you 'cause
people feel very comfortable

573
00:27:18.851 --> 00:27:22.423
working in their own lane,
and so we spend a lot

574
00:27:22.423 --> 00:27:23.938
of time trying to be in our own lane

575
00:27:23.938 --> 00:27:26.427
and parsing in our own
lanes, and I don't think

576
00:27:26.427 --> 00:27:30.594
that's actually particularly
helpful for veterans.

577
00:27:31.552 --> 00:27:33.807
Okay, and then to make matters worse,

578
00:27:33.807 --> 00:27:35.864
we do know or more complicated, we do know

579
00:27:35.864 --> 00:27:38.046
that patients with mild
TBI are twice as likely

580
00:27:38.046 --> 00:27:41.796
to develop PTSD and that
is both in military,

581
00:27:42.673 --> 00:27:44.770
not military populations,
so there is something

582
00:27:44.770 --> 00:27:49.466
about the brain, if you get a
TBI and have a traumatic event

583
00:27:49.466 --> 00:27:51.468
at the same time emotionally
and physically traumatic

584
00:27:51.468 --> 00:27:54.668
at the same time, the odds of
developing PTSD are greater

585
00:27:54.668 --> 00:27:59.129
if you have the TBI, now
why that is, we don't know.

586
00:27:59.129 --> 00:28:02.017
But that is true and I
would say that it's true

587
00:28:02.017 --> 00:28:05.203
for all kinds of psychiatric conditions.

588
00:28:05.203 --> 00:28:08.900
Okay, and we've seen
this over and over again.

589
00:28:08.900 --> 00:28:10.493
This, I think, is just
a helpful chart to think

590
00:28:10.493 --> 00:28:11.691
about all these different conditions.

591
00:28:11.691 --> 00:28:14.761
This has nothing to do with
TBI but this is comorbidities

592
00:28:14.761 --> 00:28:17.326
of mental conditions,
mental health conditions

593
00:28:17.326 --> 00:28:19.680
in those that are returning
from Iraq and Afghanistan.

594
00:28:19.680 --> 00:28:23.209
You can see how these all cluster in a way

595
00:28:23.209 --> 00:28:24.862
that is, I think, very complicated

596
00:28:24.862 --> 00:28:26.075
and not particularly satisfying

597
00:28:26.075 --> 00:28:29.575
if you're trying to say it's this or this.

598
00:28:32.489 --> 00:28:36.684
Is this what you all are
seeing, people who work in VAs?

599
00:28:36.684 --> 00:28:39.543
Yes, my friend over here,
she's working in a VA.

600
00:28:39.543 --> 00:28:40.810
(faint speaking)
Sort of?

601
00:28:40.810 --> 00:28:45.463
Okay, okay, okay, so let's
talk about TBI and suicide.

602
00:28:45.463 --> 00:28:49.481
Any questions about that before
we go, is it clear, am I?

603
00:28:49.481 --> 00:28:52.934
Okay, good, not too
overheated, okay, good.

604
00:28:52.934 --> 00:28:56.407
All right, TBI and
suicide so this right here

605
00:28:56.407 --> 00:28:59.399
is a seminal article, it came out actually

606
00:28:59.399 --> 00:29:03.070
not that long ago, in 2001
and what these folks did

607
00:29:03.070 --> 00:29:05.885
and I think this highlights
what I'm gonna say in a bit

608
00:29:05.885 --> 00:29:09.224
about what the importance of
having centralized medicine

609
00:29:09.224 --> 00:29:11.737
or electronic medical
records for huge populations.

610
00:29:11.737 --> 00:29:13.987
Many of these early
studies were done in Europe

611
00:29:13.987 --> 00:29:16.033
where they had much larger populations

612
00:29:16.033 --> 00:29:19.523
and what Teasdale and
Engberg did was found

613
00:29:19.523 --> 00:29:22.405
that people who had a history of TBI, mild

614
00:29:22.405 --> 00:29:25.319
or moderate and severe,
were about three times

615
00:29:25.319 --> 00:29:27.621
more likely to die by suicide.

616
00:29:27.621 --> 00:29:31.292
And that doesn't mean that the
reason the mild contributes

617
00:29:31.292 --> 00:29:34.225
and moderate severe
contributes is the same.

618
00:29:34.225 --> 00:29:35.439
It's interesting to think about how those

619
00:29:35.439 --> 00:29:37.133
might be the same and
different, we haven't looked

620
00:29:37.133 --> 00:29:39.796
at that yet, so I'd like
to think about mild TBI

621
00:29:39.796 --> 00:29:43.179
as a risky behavior, getting
concussions is a risky behavior

622
00:29:43.179 --> 00:29:45.467
and risky behaviors travel
together like suicide

623
00:29:45.467 --> 00:29:47.953
and other risky behaviors,
I think there's other things

624
00:29:47.953 --> 00:29:50.688
that contribute to more
moderate to severe that result

625
00:29:50.688 --> 00:29:55.106
in that same increased
risk, okay, but that's me

626
00:29:55.106 --> 00:29:57.240
making something up, I don't really know.

627
00:29:57.240 --> 00:29:58.587
But the other thing that they found out

628
00:29:58.587 --> 00:30:00.994
that I thought was really
interesting is that the risk

629
00:30:00.994 --> 00:30:04.305
wasn't right after the
TBI, the risk persisted

630
00:30:04.305 --> 00:30:06.805
for the 15 years of the study.

631
00:30:08.587 --> 00:30:11.700
And they had a maximum of 15-year follow

632
00:30:11.700 --> 00:30:14.450
so my guess is this continued.

633
00:30:14.450 --> 00:30:17.669
And so I can just tell you
from my clinical experience,

634
00:30:17.669 --> 00:30:19.613
I have veterans that I work with.

635
00:30:19.613 --> 00:30:22.381
I had a veteran with a brain
injury, took care of him

636
00:30:22.381 --> 00:30:25.205
in the hospital, he was
long post his injury.

637
00:30:25.205 --> 00:30:26.896
He had actually gone back
to school, done really,

638
00:30:26.896 --> 00:30:31.389
really well, gotten married,
having the career he wanted

639
00:30:31.389 --> 00:30:34.820
and then there was a series
of really challenging events

640
00:30:34.820 --> 00:30:36.875
and he just didn't have the resources

641
00:30:36.875 --> 00:30:40.511
and the coping strategies
and he died by suicide.

642
00:30:40.511 --> 00:30:43.103
And he was what you
would've thought well beyond

643
00:30:43.103 --> 00:30:45.444
the transition, but
really, when life changes

644
00:30:45.444 --> 00:30:49.775
start happening again, he,
there wasn't enough onboard,

645
00:30:49.775 --> 00:30:52.059
enough structure, enough
scaffolding to help him work

646
00:30:52.059 --> 00:30:54.811
through those things,
and that was probably,

647
00:30:54.811 --> 00:30:56.320
I'm trying to think how
long post his injury.

648
00:30:56.320 --> 00:30:59.490
It was long, I think it was
like 12 years post his injury.

649
00:30:59.490 --> 00:31:02.159
And seemingly, and I know not for him,

650
00:31:02.159 --> 00:31:04.942
but for me, I'd gotten an email from him

651
00:31:04.942 --> 00:31:07.266
maybe two years ago, doing great

652
00:31:07.266 --> 00:31:08.878
and so seemingly kind of out of the blue.

653
00:31:08.878 --> 00:31:11.406
Everything seems okay and
then things can change

654
00:31:11.406 --> 00:31:15.489
very quickly, okay, so in
terms of another align,

655
00:31:17.111 --> 00:31:19.551
another way to do research,
this is a systematic review

656
00:31:19.551 --> 00:31:21.615
that we did, we really
wanted to get an idea

657
00:31:21.615 --> 00:31:25.451
of all the literature that
was out there (chuckles).

658
00:31:25.451 --> 00:31:28.565
My dad's texting me jokes
right now just 'cause I guess

659
00:31:28.565 --> 00:31:32.565
it's my lucky day, so
that's hilarious actually.

660
00:31:34.207 --> 00:31:36.290
(laughs)

661
00:31:38.598 --> 00:31:39.431
Okay.

662
00:31:40.539 --> 00:31:41.836
(audience laughs)

663
00:31:41.836 --> 00:31:45.163
(chuckles) Okay, so this is a
systematic review that we did

664
00:31:45.163 --> 00:31:48.663
and who have done systematic reviews here?

665
00:31:51.011 --> 00:31:52.826
Okay, so this would be
something that Smith

666
00:31:52.826 --> 00:31:55.685
could really.
(audience laughs)

667
00:31:55.685 --> 00:31:59.158
Come on, Smith, all
right, systematic reviews

668
00:31:59.158 --> 00:32:03.126
are really important and
really a way to understand

669
00:32:03.126 --> 00:32:05.074
what's out there in
terms of the literature

670
00:32:05.074 --> 00:32:07.088
but not just the literature
but the quality of literature.

671
00:32:07.088 --> 00:32:08.901
I know aren't you glad
you asked me to come?

672
00:32:08.901 --> 00:32:10.252
Now you're probably like, oh my god.

673
00:32:10.252 --> 00:32:14.189
Okay, so it lets you do is
really, if you're interested

674
00:32:14.189 --> 00:32:16.509
in looking at an area of
research, I really recommend

675
00:32:16.509 --> 00:32:18.754
doing this, if you're
really interested in an area

676
00:32:18.754 --> 00:32:21.391
of research and you haven't
googled the topic yet,

677
00:32:21.391 --> 00:32:24.366
that would be a really great
place to start, by the way,

678
00:32:24.366 --> 00:32:26.238
'cause I probably get two
or three people a week

679
00:32:26.238 --> 00:32:29.441
that email me and say, I
have this really great idea

680
00:32:29.441 --> 00:32:31.618
and I say, have you
done a lit search on it?

681
00:32:31.618 --> 00:32:33.229
'Cause actually somebody else already had

682
00:32:33.229 --> 00:32:35.102
that really good idea, okay?
(audience chuckles)

683
00:32:35.102 --> 00:32:36.967
So just make sure that somebody
else hadn't already had

684
00:32:36.967 --> 00:32:38.630
that great idea, it
probably is a great idea

685
00:32:38.630 --> 00:32:42.082
but somebody may have already
had it, so this lets you look,

686
00:32:42.082 --> 00:32:44.582
it lets you also rate how good

687
00:32:46.917 --> 00:32:51.069
the literature is or
how good the study is.

688
00:32:51.069 --> 00:32:54.476
And so what you can see is in the history

689
00:32:54.476 --> 00:32:58.054
since 2007 to 2012,
there's actually only been

690
00:32:58.054 --> 00:33:01.887
five total studies looking
at suicide and TBI.

691
00:33:02.890 --> 00:33:05.727
You might think it's a lot
more than that, it's not.

692
00:33:05.727 --> 00:33:07.738
I know, you hear a lot
about suicide and TBI

693
00:33:07.738 --> 00:33:10.077
in the news, everything else,
but there's only five studies.

694
00:33:10.077 --> 00:33:13.442
This includes, I took out
all my CTE slides today.

695
00:33:13.442 --> 00:33:15.477
Do people know what CTE is?

696
00:33:15.477 --> 00:33:17.867
It's chronic traumatic
encephalopathy, it's the thing

697
00:33:17.867 --> 00:33:20.993
that sports thing, I took
out, but even including

698
00:33:20.993 --> 00:33:25.160
all that, there's five studies
around death by suicide.

699
00:33:26.121 --> 00:33:29.792
And only one of them has low risk of bias.

700
00:33:29.792 --> 00:33:32.229
This is a study that we did in the VA.

701
00:33:32.229 --> 00:33:33.879
I just wanna highlight this.

702
00:33:33.879 --> 00:33:36.470
It took eight million records
to be able to do this study.

703
00:33:36.470 --> 00:33:38.383
That's why it's really, really hard.

704
00:33:38.383 --> 00:33:41.846
Suicide, every suicide is super bad news

705
00:33:41.846 --> 00:33:44.721
but it is a relatively
low base rate behavior

706
00:33:44.721 --> 00:33:46.946
so if you need a population
that's large enough

707
00:33:46.946 --> 00:33:51.113
that has TBIs plus suicide,
you need a large sample

708
00:33:53.243 --> 00:33:56.796
and so this was everybody
with a history of TBI

709
00:33:56.796 --> 00:34:01.073
in the system at that
time between FY 2001, 2006

710
00:34:01.073 --> 00:34:03.384
and those without a TBI and, again,

711
00:34:03.384 --> 00:34:06.521
we found, we were very overly cautious.

712
00:34:06.521 --> 00:34:08.461
We controlled for all
psychiatric conditions

713
00:34:08.461 --> 00:34:11.634
so we probably took out a
lot of our TBI symptoms.

714
00:34:11.634 --> 00:34:13.071
Does that make sense,
remember I already talked

715
00:34:13.071 --> 00:34:16.472
about psychiatric symptoms
and we still found

716
00:34:16.472 --> 00:34:20.749
about two times increased
risk with those with TBI.

717
00:34:20.749 --> 00:34:23.898
This is the other thing I wanna show you.

718
00:34:23.898 --> 00:34:27.161
So this is those who
did not die by suicide,

719
00:34:27.161 --> 00:34:29.624
those who did die by suicide, and this

720
00:34:29.624 --> 00:34:31.599
is major depressive
disorder, on the top here,

721
00:34:31.599 --> 00:34:34.695
you have really more
concussions, mild TBI moderate

722
00:34:34.695 --> 00:34:36.605
to severe and I just wanna
show you the really high rates

723
00:34:36.605 --> 00:34:38.193
of major depressive disorder.

724
00:34:38.193 --> 00:34:40.645
So those who did die by suicide, 30% had

725
00:34:40.645 --> 00:34:44.480
major depressive disorder,
those who didn't, still 10%

726
00:34:44.480 --> 00:34:48.647
and 21% and 8%, so just really
highly rates of individuals

727
00:34:50.170 --> 00:34:51.868
walking around with these conditions

728
00:34:51.868 --> 00:34:54.006
with untreated mental health disorders

729
00:34:54.006 --> 00:34:57.104
and I'll talk more about that as I go.

730
00:34:57.104 --> 00:34:58.369
This is a nice study that was done

731
00:34:58.369 --> 00:35:02.043
at University Washington,
actually a great rehab folks

732
00:35:02.043 --> 00:35:04.683
in Seattle and what
they get is they looked

733
00:35:04.683 --> 00:35:08.350
at accumulative onset
of depression post TBI

734
00:35:09.396 --> 00:35:13.446
and they found that their
sample, almost 50% of the sample

735
00:35:13.446 --> 00:35:16.953
in the first year post TBI
had major depressive disorder.

736
00:35:16.953 --> 00:35:20.133
Okay, so if you think
you're going to go out

737
00:35:20.133 --> 00:35:22.468
and have a clinical
practice in social work

738
00:35:22.468 --> 00:35:26.656
and not see people who have
TBI, you are wrong (chuckles).

739
00:35:26.656 --> 00:35:29.846
You're just wrong and if
you're in practice already

740
00:35:29.846 --> 00:35:32.109
and you're not asking
about history of TBI,

741
00:35:32.109 --> 00:35:33.959
you're probably treating
people who have history of TBI

742
00:35:33.959 --> 00:35:36.446
and you just don't know
it, okay, so that would be

743
00:35:36.446 --> 00:35:39.433
another thing to take from
today is it's really helpful

744
00:35:39.433 --> 00:35:42.123
to know if this part
of somebody's history.

745
00:35:42.123 --> 00:35:43.896
And my sense is you're probably
already doing this work.

746
00:35:43.896 --> 00:35:45.979
You just may not know it.

747
00:35:47.061 --> 00:35:50.581
Okay, this was why I did
go back to actually look

748
00:35:50.581 --> 00:35:52.933
'cause I was thinking,
okay, I'm going to Smith

749
00:35:52.933 --> 00:35:55.633
and I wanna make sure I can
talk about women and TBI

750
00:35:55.633 --> 00:35:57.283
'cause that seemed like
the right thing to do

751
00:35:57.283 --> 00:36:01.394
and embarrassingly, we have
no women in this study.

752
00:36:01.394 --> 00:36:03.778
And actually I started to
look at a bunch of studies.

753
00:36:03.778 --> 00:36:07.281
There is no women in any of these studies

754
00:36:07.281 --> 00:36:11.280
so if you are looking
for a research career,

755
00:36:11.280 --> 00:36:12.939
there is a career out there to be had

756
00:36:12.939 --> 00:36:16.244
about women and TBI,
there is this great group

757
00:36:16.244 --> 00:36:18.491
called Pink Concussions
if you're on Twitter.

758
00:36:18.491 --> 00:36:21.130
They're starting to do some
work but finding large enough

759
00:36:21.130 --> 00:36:24.544
cohorts of women, where
people are recording TBI

760
00:36:24.544 --> 00:36:28.108
and negative psychiatric outcomes,
that would be a challenge

761
00:36:28.108 --> 00:36:30.543
but something worth us
thinking about together

762
00:36:30.543 --> 00:36:33.904
so I invite you to help me
think about how to do that

763
00:36:33.904 --> 00:36:38.207
but I just wanna tell you
this was a sad moment for me

764
00:36:38.207 --> 00:36:40.619
when I realized this, so
thank you for inviting me

765
00:36:40.619 --> 00:36:42.455
here so I could look
so I realized this work

766
00:36:42.455 --> 00:36:45.406
still really needs to be done.

767
00:36:45.406 --> 00:36:47.858
Okay, let's talk about
ideation and attempts

768
00:36:47.858 --> 00:36:50.166
so this is actually engaging in behavior

769
00:36:50.166 --> 00:36:52.858
that you don't die from
and thinking about it.

770
00:36:52.858 --> 00:36:57.190
There's only two studies in
this period, two total studies,

771
00:36:57.190 --> 00:36:58.756
and they both actually stink, I know,

772
00:36:58.756 --> 00:37:00.390
'cause they're both from my lab.

773
00:37:00.390 --> 00:37:02.418
Okay (chuckles) they're
really bad studies.

774
00:37:02.418 --> 00:37:04.533
They actually weren't
done to identify rates,

775
00:37:04.533 --> 00:37:06.931
prevalence rates, so they're really bad.

776
00:37:06.931 --> 00:37:09.619
So like no studies really
about suicide attempts

777
00:37:09.619 --> 00:37:12.965
in those with TBI, and then really, again,

778
00:37:12.965 --> 00:37:16.509
two studies about ideation, this is total.

779
00:37:16.509 --> 00:37:18.448
This one's pretty good,
this is our colleagues

780
00:37:18.448 --> 00:37:22.136
at Mount Sinai, about 28,
you'll see 25% to 28% of people

781
00:37:22.136 --> 00:37:25.803
thinking about dying
by suicide after a TBI.

782
00:37:28.034 --> 00:37:31.984
And so what you really see is
that we know that people die

783
00:37:31.984 --> 00:37:34.223
by suicide about three times the rate.

784
00:37:34.223 --> 00:37:36.809
We have very little data about attempts

785
00:37:36.809 --> 00:37:39.809
and very little data about ideation.

786
00:37:41.548 --> 00:37:43.118
Remember how I said it's really gratifying

787
00:37:43.118 --> 00:37:44.919
to see other people
starting to do this work?

788
00:37:44.919 --> 00:37:48.282
So this is since the
systematic review, again, 25%

789
00:37:48.282 --> 00:37:50.302
are reporting SI, this is another study

790
00:37:50.302 --> 00:37:51.921
from University of Washington and about

791
00:37:51.921 --> 00:37:54.180
a threefold increase, so if
you wanna just take some things

792
00:37:54.180 --> 00:37:56.620
home, attempt data we
don't have anything good

793
00:37:56.620 --> 00:37:59.846
on yet really, three times
the rate of suicide deaths

794
00:37:59.846 --> 00:38:02.875
in about 25% of people
thinking about suicide anytime

795
00:38:02.875 --> 00:38:06.876
after a brain injury, just
that's a lot, it's a quarter.

796
00:38:06.876 --> 00:38:10.293
Okay, so risk factors in this population.

797
00:38:13.095 --> 00:38:15.420
So one big thing is this
loss of sense of self.

798
00:38:15.420 --> 00:38:17.235
This is a qualitative study that we did.

799
00:38:17.235 --> 00:38:19.995
We interviewed folks about
what it was like to live

800
00:38:19.995 --> 00:38:23.433
with a TBI after and this
veteran spoke consistently

801
00:38:23.433 --> 00:38:26.868
about this not being who they
used to be, losing themselves

802
00:38:26.868 --> 00:38:28.433
and this is, when you have a brain injury,

803
00:38:28.433 --> 00:38:30.458
it's kinda like two
different people that splits.

804
00:38:30.458 --> 00:38:31.658
It's like a split personality.

805
00:38:31.658 --> 00:38:33.722
You have the person that's
still walking around

806
00:38:33.722 --> 00:38:35.933
but then you have the other
person who's the brain trauma

807
00:38:35.933 --> 00:38:37.522
and this, I think, is really important

808
00:38:37.522 --> 00:38:39.958
'cause there's nothing
beyond for this person

809
00:38:39.958 --> 00:38:41.958
than their brain injury.

810
00:38:42.820 --> 00:38:44.660
Psychiatric and emotional distress,

811
00:38:44.660 --> 00:38:46.509
we've talked about risk
factor quite a bit.

812
00:38:46.509 --> 00:38:49.330
I get depressed about a lot
of things and figured my wife

813
00:38:49.330 --> 00:38:51.745
could use the $400,000
tax-free life insurance plan

814
00:38:51.745 --> 00:38:54.332
a lot better, I went jogging
one morning, felt this bad,

815
00:38:54.332 --> 00:38:55.907
and said, "Well, it's
gonna be easier for me

816
00:38:55.907 --> 00:38:58.793
"to slip and fall into the
next truck that goes by."

817
00:38:58.793 --> 00:39:00.722
Okay, this is particularly
concerning if you have

818
00:39:00.722 --> 00:39:05.294
impulse control and
problem-solving difficulties.

819
00:39:05.294 --> 00:39:07.108
And this is a study that was done.

820
00:39:07.108 --> 00:39:09.708
You'll hear me talk more about
my colleague Grahame Simpson.

821
00:39:09.708 --> 00:39:13.008
They looked and they found
that if folks had psychiatric

822
00:39:13.008 --> 00:39:15.507
and emotional disturbance of
any kind, plus substance abuse,

823
00:39:15.507 --> 00:39:17.670
21 times more likely to
have made a suicide attempt

824
00:39:17.670 --> 00:39:19.457
with a history of TBI, right?

825
00:39:19.457 --> 00:39:21.807
So if you are doing
your clinical practice,

826
00:39:21.807 --> 00:39:24.218
you have somebody you know
(chuckles) has a history of TBI

827
00:39:24.218 --> 00:39:26.057
and substance abuse and any psychiatric,

828
00:39:26.057 --> 00:39:29.955
emotional disturbance and you
are not doing safety planning

829
00:39:29.955 --> 00:39:34.007
and doing suicide risk
assessment, not only are you doing

830
00:39:34.007 --> 00:39:35.843
bad clinical care, but I think
you're opening yourself up

831
00:39:35.843 --> 00:39:39.045
to malpractice, all right,
so this would be something

832
00:39:39.045 --> 00:39:41.346
that you really need to
be paying attention to.

833
00:39:41.346 --> 00:39:44.263
That is just a huge increased risk.

834
00:39:46.570 --> 00:39:49.871
Okay, and hopelessness,
about 33% of those with TBI

835
00:39:49.871 --> 00:39:51.658
endured moderate to severe hopelessness

836
00:39:51.658 --> 00:39:53.895
between one and 10 years post injury.

837
00:39:53.895 --> 00:39:56.860
And you see that idea that it doesn't end.

838
00:39:56.860 --> 00:39:59.171
10 years post is only 'cause
they stopped measuring

839
00:39:59.171 --> 00:40:01.020
at 10 years, it's not 'cause everything

840
00:40:01.020 --> 00:40:02.937
got better at 10 years.

841
00:40:04.345 --> 00:40:06.883
And then also cognitive
impairment was identified

842
00:40:06.883 --> 00:40:10.168
by veterans as a risk factor,
I knew what I wanted to say

843
00:40:10.168 --> 00:40:12.108
although I'd get a thought
about halfway through it

844
00:40:12.108 --> 00:40:14.282
and it would just dissolve in my brain.

845
00:40:14.282 --> 00:40:16.843
I wouldn't know where it
was, and five minutes later,

846
00:40:16.843 --> 00:40:19.283
I couldn't even remember
that a had the thought.

847
00:40:19.283 --> 00:40:20.685
And that added to a lot of frustration

848
00:40:20.685 --> 00:40:22.595
because of the condition,
a couple of days later,

849
00:40:22.595 --> 00:40:25.196
you can't even remember what
you were frustrated about.

850
00:40:25.196 --> 00:40:27.821
And this one I think is really pertinent

851
00:40:27.821 --> 00:40:29.942
with the hopelessness, I get
to the point where I fight

852
00:40:29.942 --> 00:40:34.109
with my memory and other things
and it's just not worth it.

853
00:40:35.758 --> 00:40:38.618
Okay, and so then I'm
particularly interested

854
00:40:38.618 --> 00:40:41.870
in cognitive functioning so I like this

855
00:40:41.870 --> 00:40:45.296
because this is
qualitative data telling me

856
00:40:45.296 --> 00:40:47.296
that cognitive functioning is a problem,

857
00:40:47.296 --> 00:40:49.496
but when I do research I
like to converge on ideas

858
00:40:49.496 --> 00:40:52.233
from all different sides
using different methods.

859
00:40:52.233 --> 00:40:54.136
So that's the qualitative side.

860
00:40:54.136 --> 00:40:57.032
Here's the quantitative side, we did,

861
00:40:57.032 --> 00:40:59.345
used neuropsych measures
to look at things,

862
00:40:59.345 --> 00:41:01.499
decision-making, impulsivity, aggression

863
00:41:01.499 --> 00:41:03.633
and other executive dysfunctions,

864
00:41:03.633 --> 00:41:06.320
and I won't get too into the
neurospychyness of it here

865
00:41:06.320 --> 00:41:09.156
but I think some really interesting
data that came out here,

866
00:41:09.156 --> 00:41:12.545
we looked at four groups,
no suicide, no TBI.

867
00:41:12.545 --> 00:41:17.083
No suicide, yes TBI, yes
suicide, no TBI, and both.

868
00:41:17.083 --> 00:41:18.308
And I just want you to look at number

869
00:41:18.308 --> 00:41:22.770
of lifetime psychiatric
diagnoses in this group here,

870
00:41:22.770 --> 00:41:26.603
12, right, 12 people
have more, 12, I'm sorry.

871
00:41:28.383 --> 00:41:31.858
12 had more than two lifetime
psychiatric diagnoses

872
00:41:31.858 --> 00:41:35.858
and here, what you see is number
of psychoactive medications

873
00:41:35.858 --> 00:41:39.706
currently being taken, so
these folks are already taking

874
00:41:39.706 --> 00:41:43.081
three medications in
this group and still not,

875
00:41:43.081 --> 00:41:45.831
what I would say, doing
particularly better.

876
00:41:45.831 --> 00:41:48.164
Right, does that make sense?

877
00:41:50.546 --> 00:41:55.046
And then this is just some
outcome questionnaire 45

878
00:41:55.046 --> 00:41:56.887
just psychological distress, this group's

879
00:41:56.887 --> 00:41:58.995
much more distressed than the other groups

880
00:41:58.995 --> 00:42:01.122
and also has much more ideation

881
00:42:01.122 --> 00:42:05.021
than other groups, so even
this group, even much more

882
00:42:05.021 --> 00:42:08.211
so than the suicide
group and the TBI group,

883
00:42:08.211 --> 00:42:11.360
just much more complicated, this group.

884
00:42:11.360 --> 00:42:13.957
And so what we did is gave
them the Iowa gambling test.

885
00:42:13.957 --> 00:42:16.746
Are people familiar
with Iowa gambling test?

886
00:42:16.746 --> 00:42:19.573
So it's actually this pretty
cool test that you have.

887
00:42:19.573 --> 00:42:22.160
It's like gambling, which
is fun for people, right?

888
00:42:22.160 --> 00:42:24.935
And it's this game and
it's high risk, high reward

889
00:42:24.935 --> 00:42:28.445
and people either do impulsive
way-out-of control gambling

890
00:42:28.445 --> 00:42:30.421
on it or they realize if you're cautious,

891
00:42:30.421 --> 00:42:32.310
you can make more money over time.

892
00:42:32.310 --> 00:42:34.036
Okay, so we thought we
had all these ideas.

893
00:42:34.036 --> 00:42:36.036
We thought we were really
smart about all these ideas

894
00:42:36.036 --> 00:42:38.010
about what people were
gonna do on the test

895
00:42:38.010 --> 00:42:40.571
but what we actually found
out is that the group

896
00:42:40.571 --> 00:42:44.396
that had both, they actually
just didn't do the test.

897
00:42:44.396 --> 00:42:45.896
They just gave up.

898
00:42:46.773 --> 00:42:50.071
They didn't problem
solve, they didn't try.

899
00:42:50.071 --> 00:42:53.436
They couldn't think about
it, they just stopped trying.

900
00:42:53.436 --> 00:42:56.296
And I think this is really
important based on some

901
00:42:56.296 --> 00:42:59.036
of the qualitative data we've see already.

902
00:42:59.036 --> 00:43:01.121
The qualitative data helps me make sense

903
00:43:01.121 --> 00:43:04.446
of it's just not worth
it, I'm just giving up.

904
00:43:04.446 --> 00:43:07.134
I can't figure this out and if we think

905
00:43:07.134 --> 00:43:10.060
about suicide prevention
in a group who is just,

906
00:43:10.060 --> 00:43:12.410
doesn't know how to
start to figure it out.

907
00:43:12.410 --> 00:43:14.735
That is a huge problem,
right, 'cause I'll talk later

908
00:43:14.735 --> 00:43:17.310
about safety planning,
if I say to somebody,

909
00:43:17.310 --> 00:43:20.236
use your safety plan, and
they just can barely get

910
00:43:20.236 --> 00:43:22.246
into it and start to just stop,

911
00:43:22.246 --> 00:43:25.323
that's not particularly
helpful, does that make sense?

912
00:43:25.323 --> 00:43:29.244
I know that's kinda neuropsychy,
but I think it's important.

913
00:43:29.244 --> 00:43:33.086
Okay, so let's talk about intervention.

914
00:43:33.086 --> 00:43:35.723
So how many interventions,
I showed you the five

915
00:43:35.723 --> 00:43:38.109
and the two and the two, how
many interventions do you think

916
00:43:38.109 --> 00:43:42.109
had been done to date
around those interventions

917
00:43:43.740 --> 00:43:46.828
for people with TBI around suicide?

918
00:43:46.828 --> 00:43:49.753
Zero, zero, it's better than zero.

919
00:43:49.753 --> 00:43:50.586
One.

920
00:43:52.676 --> 00:43:56.676
One study, 17 people,
that was the total, right?

921
00:43:57.818 --> 00:44:01.415
Another really good area for research.

922
00:44:01.415 --> 00:44:03.629
So this is the total that we had.

923
00:44:03.629 --> 00:44:05.191
We actually have been more than this now.

924
00:44:05.191 --> 00:44:09.655
This was a 10-session intervention
targeting hopelessness.

925
00:44:09.655 --> 00:44:13.205
It was done by our colleague
in Australia, Grahame Simpson,

926
00:44:13.205 --> 00:44:15.652
and basically what
Grahame found is if he did

927
00:44:15.652 --> 00:44:17.342
this small group intervention,
I'm gonna tell you

928
00:44:17.342 --> 00:44:19.718
a little bit about the
intervention, folks got

929
00:44:19.718 --> 00:44:23.755
significantly less hopeless,
and what you have basically

930
00:44:23.755 --> 00:44:27.117
is that folks, the wait-list
group got the intervention too

931
00:44:27.117 --> 00:44:30.893
and they, both groups got better after.

932
00:44:30.893 --> 00:44:35.348
And so this is the idea, that
TBI results in hopelessness.

933
00:44:35.348 --> 00:44:37.348
Hopelessness results in suicide ideation,

934
00:44:37.348 --> 00:44:39.098
then suicide attempt.

935
00:44:40.850 --> 00:44:44.425
It uses a lot of things
that you know about already.

936
00:44:44.425 --> 00:44:47.190
You may not think that they're
good but they're really good,

937
00:44:47.190 --> 00:44:50.038
especially for this group,
things like learning

938
00:44:50.038 --> 00:44:52.006
about how to be behaviorally activated

939
00:44:52.006 --> 00:44:55.081
and having a positive
lifestyle, working on thoughts,

940
00:44:55.081 --> 00:44:59.248
working on problem-solving,
using compensatory techniques,

941
00:45:00.138 --> 00:45:02.606
and it is really trying
to help people address

942
00:45:02.606 --> 00:45:05.627
their negative feelings and learning ways

943
00:45:05.627 --> 00:45:07.960
to deal with their problems.

944
00:45:09.932 --> 00:45:13.944
The intervention, so this is
the window, window to hope,

945
00:45:13.944 --> 00:45:15.396
and so what you're doing, you know folks

946
00:45:15.396 --> 00:45:17.985
have memory-related problems
so you have a small group

947
00:45:17.985 --> 00:45:20.049
so that there's people in the
group, two or three people

948
00:45:20.049 --> 00:45:22.501
so other people can tell, they
can tell each other things

949
00:45:22.501 --> 00:45:24.211
that you may not want to
tell them as the therapist

950
00:45:24.211 --> 00:45:26.326
but you can also be there
but there's plenty of time

951
00:45:26.326 --> 00:45:28.751
for scaffolding and support.

952
00:45:28.751 --> 00:45:32.322
Each of the window panes is a concept.

953
00:45:32.322 --> 00:45:34.576
Each of the concept has
mnemonics and you're teaching

954
00:45:34.576 --> 00:45:39.286
the mnemonics, you're helping
them overlearn the concepts,

955
00:45:39.286 --> 00:45:42.171
and you're managing very
complicated relationships

956
00:45:42.171 --> 00:45:44.412
in the room so what you're
trying to do is manage

957
00:45:44.412 --> 00:45:46.950
very complicated relationships
and very intense feelings

958
00:45:46.950 --> 00:45:50.298
around loss, but trying to teach skills.

959
00:45:50.298 --> 00:45:54.087
And that is really hard, that's
very hard therapeutic work.

960
00:45:54.087 --> 00:45:57.387
If you cannot create
relationships with these folks

961
00:45:57.387 --> 00:45:59.737
and help them create
relationships with each other,

962
00:45:59.737 --> 00:46:01.997
none of these concepts
are actually gonna matter

963
00:46:01.997 --> 00:46:03.408
'cause they're gonna be like, "This sucks,

964
00:46:03.408 --> 00:46:07.897
"and I'm not learning, I don't
like going there," right?

965
00:46:07.897 --> 00:46:10.767
Lots of homework and things
around behavioral activation,

966
00:46:10.767 --> 00:46:13.854
helping keep track of things.

967
00:46:13.854 --> 00:46:15.304
I'm just showing you some
of the different things.

968
00:46:15.304 --> 00:46:17.380
They should look familiar,
cognitive restructuring,

969
00:46:17.380 --> 00:46:20.419
very basic concepts,
problem-solving, and this idea

970
00:46:20.419 --> 00:46:24.319
of building hope, so I really,
I thought, this is awesome

971
00:46:24.319 --> 00:46:25.892
and Grahame is awesome so
maybe we could bring this

972
00:46:25.892 --> 00:46:27.914
to the U.S., so we brought it to the U.S.

973
00:46:27.914 --> 00:46:30.315
This is the DoD, Grahame
had a different window

974
00:46:30.315 --> 00:46:32.290
that the DoD thought
wasn't masculine enough.

975
00:46:32.290 --> 00:46:35.230
This was my more masculine
window, do you like it?

976
00:46:35.230 --> 00:46:36.421
(audience laughs)

977
00:46:36.421 --> 00:46:38.192
My staff is searching
for four-pane windows

978
00:46:38.192 --> 00:46:41.517
for quite some time, it actually sends,

979
00:46:41.517 --> 00:46:43.130
people have told us it's
like looking up to heaven

980
00:46:43.130 --> 00:46:45.392
so maybe not that great for
suicide-prevention intervention

981
00:46:45.392 --> 00:46:47.942
so if you have a better window for me,

982
00:46:47.942 --> 00:46:50.290
I'm very happy to see it.

983
00:46:50.290 --> 00:46:52.363
This took a lot of effort and time.

984
00:46:52.363 --> 00:46:55.042
We did a randomized clinical trial.

985
00:46:55.042 --> 00:46:58.942
You can see my beautiful consort diagram

986
00:46:58.942 --> 00:47:01.729
and what we did and just
this is your hint for the day

987
00:47:01.729 --> 00:47:04.662
around clinical trials,
we made sure everybody had

988
00:47:04.662 --> 00:47:06.662
a Beck score of nine,
which meant that there was

989
00:47:06.662 --> 00:47:09.662
moderately hopeless so
they could actually benefit

990
00:47:09.662 --> 00:47:11.860
from the intervention, we
were having a lot of trouble

991
00:47:11.860 --> 00:47:13.924
recruiting and a lot of
times people were like,

992
00:47:13.924 --> 00:47:15.412
why don't you just bring
that Beck score down?

993
00:47:15.412 --> 00:47:17.760
We could get people, we have
a people who have fives.

994
00:47:17.760 --> 00:47:18.885
We have a lot of people who have sixes.

995
00:47:18.885 --> 00:47:21.060
I was like, if we let everybody
who is fives and sixes,

996
00:47:21.060 --> 00:47:23.307
there's nowhere to go
for the intervention.

997
00:47:23.307 --> 00:47:24.989
We'll have a negative trial.

998
00:47:24.989 --> 00:47:27.727
I cannot tell you how many
negative TBI trials there's been.

999
00:47:27.727 --> 00:47:32.463
So just if you're gonna be a
clinical trialist, hold fast

1000
00:47:32.463 --> 00:47:35.448
on giving yourself room to go down.

1001
00:47:35.448 --> 00:47:37.954
And basically this is what we found.

1002
00:47:37.954 --> 00:47:41.294
So this is the Beck Hopelessness Scale

1003
00:47:41.294 --> 00:47:44.853
and this is group one,
so this is people who got

1004
00:47:44.853 --> 00:47:48.257
the intervention first,
this is their hopelessness

1005
00:47:48.257 --> 00:47:51.481
at baseline, post treatment,
and then they maintain.

1006
00:47:51.481 --> 00:47:53.478
This is baseline, they're the weight group

1007
00:47:53.478 --> 00:47:55.385
and then they got the intervention.

1008
00:47:55.385 --> 00:47:59.573
So positive trial for window to hope, woo!

1009
00:47:59.573 --> 00:48:01.455
And also just a other
thing is just like we had

1010
00:48:01.455 --> 00:48:03.944
statistical significance but did we have

1011
00:48:03.944 --> 00:48:07.339
clinically meaningful change, and we do.

1012
00:48:07.339 --> 00:48:09.345
I read lots and lots of
papers where I have these

1013
00:48:09.345 --> 00:48:11.959
really beautiful big
statistical change numbers

1014
00:48:11.959 --> 00:48:15.689
but they're clinically
meaningless, that make sense?

1015
00:48:15.689 --> 00:48:18.522
So please make sure you have both.

1016
00:48:19.732 --> 00:48:21.122
Here's the million-dollar question though.

1017
00:48:21.122 --> 00:48:23.275
We've had two trials that are positive,

1018
00:48:23.275 --> 00:48:25.719
neither of them huge, now what?

1019
00:48:25.719 --> 00:48:28.000
How do we implement this
nationally or beyond

1020
00:48:28.000 --> 00:48:30.451
our multi-site trial and
who wants to fund that?

1021
00:48:30.451 --> 00:48:32.062
That's a different issue
for a different day

1022
00:48:32.062 --> 00:48:34.773
but it's really, really hard
to get new interventions

1023
00:48:34.773 --> 00:48:38.211
out there, particularly for
specialized populations.

1024
00:48:38.211 --> 00:48:39.488
And I'm not gonna go through all of these

1025
00:48:39.488 --> 00:48:42.411
but I just wanna show you we
also collect qualitative data

1026
00:48:42.411 --> 00:48:44.889
as well as our quantitative
data to help us understand

1027
00:48:44.889 --> 00:48:47.167
why the people like
the intervention, okay?

1028
00:48:47.167 --> 00:48:49.715
So I'd really recommend doing that.

1029
00:48:49.715 --> 00:48:51.340
I'm not gonna go through those.

1030
00:48:51.340 --> 00:48:55.373
Okay, and then this study, I
can't get it out of my mind.

1031
00:48:55.373 --> 00:48:56.510
So I was like, okay, what are we gonna do?

1032
00:48:56.510 --> 00:48:57.762
So I'll tell you one
thing I don't have slides

1033
00:48:57.762 --> 00:49:00.564
in here about, we're doing
this thing where we're having,

1034
00:49:00.564 --> 00:49:01.883
it's an app on people's phones

1035
00:49:01.883 --> 00:49:04.854
and it passively monitors their behavior

1036
00:49:04.854 --> 00:49:07.918
and what is it just runs in
the background and so if they,

1037
00:49:07.918 --> 00:49:10.212
you get a baseline, they
get a texts, they go out

1038
00:49:10.212 --> 00:49:12.976
in the community, they
do their normal living

1039
00:49:12.976 --> 00:49:15.146
and I get a dashboard every day that shows

1040
00:49:15.146 --> 00:49:17.937
how they're doing and so
even if you don't recognize

1041
00:49:17.937 --> 00:49:19.442
you're having a hard time, I
can recognize you're having

1042
00:49:19.442 --> 00:49:21.771
a hard time by watching your dashboard.

1043
00:49:21.771 --> 00:49:23.241
So that's one intervention
that we're doing right now.

1044
00:49:23.241 --> 00:49:24.756
We thought veterans would
hate it 'cause they'd think

1045
00:49:24.756 --> 00:49:27.970
it's like a privacy
problems, they don't care.

1046
00:49:27.970 --> 00:49:30.164
They've been great, they're
really happy to have somebody

1047
00:49:30.164 --> 00:49:33.471
looking after them, it's been
really interesting to see

1048
00:49:33.471 --> 00:49:36.501
that they feel like the
VA's taking care of them.

1049
00:49:36.501 --> 00:49:38.872
We are but like really it's
like me and my staff watching

1050
00:49:38.872 --> 00:49:41.223
their numbers every day but
they feel very cared for,

1051
00:49:41.223 --> 00:49:45.507
even though I'm using computer
algorithms to monitor them.

1052
00:49:45.507 --> 00:49:47.608
So there's different ways
we can extend ourselves

1053
00:49:47.608 --> 00:49:50.403
that are creative and it
doesn't require anything

1054
00:49:50.403 --> 00:49:53.891
from them, other than letting
us load it on their phone.

1055
00:49:53.891 --> 00:49:56.223
We can also push measures on here too.

1056
00:49:56.223 --> 00:49:58.239
I can present on this a different time.

1057
00:49:58.239 --> 00:49:59.530
I had to really choose
(chuckles) what I presented

1058
00:49:59.530 --> 00:50:01.597
on today, so I didn't present on that.

1059
00:50:01.597 --> 00:50:04.541
But this was another
intervention that we tried, yeah?

1060
00:50:04.541 --> 00:50:07.291
(faint speaking)

1061
00:50:08.153 --> 00:50:11.810
So we're working this company
actually, it's in Boston,

1062
00:50:11.810 --> 00:50:14.234
and so they've created these algorithms

1063
00:50:14.234 --> 00:50:16.837
and so some of the main
stuff that goes into it

1064
00:50:16.837 --> 00:50:19.313
is actually out and about,
so are they actually leaving

1065
00:50:19.313 --> 00:50:21.728
their house, and it measures GPS wise,

1066
00:50:21.728 --> 00:50:24.210
are they actually leaving,
it measures how many texts

1067
00:50:24.210 --> 00:50:26.993
and phone calls they're getting
so things like isolation

1068
00:50:26.993 --> 00:50:29.920
so it's really just very basic
things that it's monitoring

1069
00:50:29.920 --> 00:50:32.829
and then we also do push measures to them.

1070
00:50:32.829 --> 00:50:35.889
Okay, so this is another model, right

1071
00:50:35.889 --> 00:50:37.115
so if you're gonna do
interventional trials,

1072
00:50:37.115 --> 00:50:40.978
you need to think about
what's the mechanism.

1073
00:50:40.978 --> 00:50:43.092
Don't just tell me you think
something's a good idea

1074
00:50:43.092 --> 00:50:45.561
for intervention, think about
why is it a good intervention,

1075
00:50:45.561 --> 00:50:47.610
what's the mechanism for change.

1076
00:50:47.610 --> 00:50:50.251
So this is here we have
the failed problem-solving.

1077
00:50:50.251 --> 00:50:51.279
We have a stressful life event.

1078
00:50:51.279 --> 00:50:53.426
We already know that people
have cognitive impairment,

1079
00:50:53.426 --> 00:50:56.933
hopelessness, failed
problem-solving, increased distress.

1080
00:50:56.933 --> 00:51:01.016
I can't think of any other options, right?

1081
00:51:01.016 --> 00:51:04.528
You see how I got from here
to something that seems

1082
00:51:04.528 --> 00:51:08.520
much more clinical here,
I don't like research.

1083
00:51:08.520 --> 00:51:12.349
It's boring, actually it's very helpful.

1084
00:51:12.349 --> 00:51:15.005
Do you see how research
helps me make a mechanism

1085
00:51:15.005 --> 00:51:17.812
that actually could have an intervention?

1086
00:51:17.812 --> 00:51:21.321
If I don't have this,
I don't think of this.

1087
00:51:21.321 --> 00:51:23.481
Does that make sense?

1088
00:51:23.481 --> 00:51:26.129
And then I think of this,
oh, we need intervention

1089
00:51:26.129 --> 00:51:29.024
so we create an
intervention based off this,

1090
00:51:29.024 --> 00:51:32.681
which is really based off
this boring neuropsych study.

1091
00:51:32.681 --> 00:51:34.083
Does that make sense?
- Yeah.

1092
00:51:34.083 --> 00:51:38.458
- Okay, so we did this thing
where we paired problem-solving

1093
00:51:38.458 --> 00:51:41.161
therapy, who here knows
problem-solving therapy?

1094
00:51:41.161 --> 00:51:44.243
If you don't, it's really
good transdiagnostic therapy.

1095
00:51:44.243 --> 00:51:47.326
You should know it, it's way helpful.

1096
00:51:48.378 --> 00:51:50.229
It's actually really helpful,
problem-solving therapy.

1097
00:51:50.229 --> 00:51:53.472
Art Nezu is a prince, he is amazing.

1098
00:51:53.472 --> 00:51:56.684
You should have Art come,
he's way smarter than I am

1099
00:51:56.684 --> 00:51:59.250
and he's super nice, probably
way nicer than I am too,

1100
00:51:59.250 --> 00:52:00.880
actually.
(audience laughs)

1101
00:52:00.880 --> 00:52:04.638
So we paired problem-solving
therapy with safety planning

1102
00:52:04.638 --> 00:52:07.310
and we did, again, some
really basic things

1103
00:52:07.310 --> 00:52:09.748
about how do you do problem-solving,
how do you recognize

1104
00:52:09.748 --> 00:52:12.415
triggers, problem-solving steps.

1105
00:52:13.654 --> 00:52:16.109
And this is the basic
premise of the intervention.

1106
00:52:16.109 --> 00:52:18.467
There's stress, there's
problem-solving ability

1107
00:52:18.467 --> 00:52:21.386
and if you don't, if your
stress gets too great

1108
00:52:21.386 --> 00:52:23.700
and you don't have enough
problem-solving strategies,

1109
00:52:23.700 --> 00:52:25.565
skills, and crisis-response planning,

1110
00:52:25.565 --> 00:52:28.533
then it's gonna break, it's
not like rocket science.

1111
00:52:28.533 --> 00:52:31.691
But actually, I know you
all spend a lot of time

1112
00:52:31.691 --> 00:52:33.990
thinking about your thoughts,
feelings, and behaviors.

1113
00:52:33.990 --> 00:52:37.775
Most people in America
do not do that, right?

1114
00:52:37.775 --> 00:52:39.966
People don't think
about this all the time.

1115
00:52:39.966 --> 00:52:42.334
I know you like to, I like to.

1116
00:52:42.334 --> 00:52:44.570
My husband's a therapist,
I have four children,

1117
00:52:44.570 --> 00:52:47.523
think about it, even
though they don't want to.

1118
00:52:47.523 --> 00:52:49.718
Most people don't think about this.

1119
00:52:49.718 --> 00:52:51.888
They don't think, wow, I'm
feeling really triggered

1120
00:52:51.888 --> 00:52:53.589
and I don't have enough
problem-solving skills.

1121
00:52:53.589 --> 00:52:56.506
I should use my safety plan, right?

1122
00:52:59.215 --> 00:53:03.382
So we teach problem-solving
steps, triggers,

1123
00:53:03.382 --> 00:53:06.613
really very basic but stuff,
people haven't thought

1124
00:53:06.613 --> 00:53:10.780
about this before, they
really haven't, warning signs.

1125
00:53:11.856 --> 00:53:14.257
Warning signs are actually
better than risk factors

1126
00:53:14.257 --> 00:53:17.845
in terms of individual
thoughts, feelings and behaviors

1127
00:53:17.845 --> 00:53:21.249
that contribute to people
feeling more suicidal

1128
00:53:21.249 --> 00:53:23.877
so risk factors are
epidemiologically based.

1129
00:53:23.877 --> 00:53:26.699
Warning signs are person specific.

1130
00:53:26.699 --> 00:53:28.561
Warning signs would be
something to learn more about.

1131
00:53:28.561 --> 00:53:29.856
I'm sorry I don't have
enough time for it today

1132
00:53:29.856 --> 00:53:34.790
but so beliefs, physical
sensations, behaviors, and emotions

1133
00:53:34.790 --> 00:53:38.398
person specific, unhelpful thoughts.

1134
00:53:38.398 --> 00:53:41.090
This is my favorite one,
PASTA, we were trying to think

1135
00:53:41.090 --> 00:53:42.816
of something that was a different acronym

1136
00:53:42.816 --> 00:53:46.217
that I really didn't like around pausing,

1137
00:53:46.217 --> 00:53:48.578
becoming aware, slowing
down, thinking, and acting.

1138
00:53:48.578 --> 00:53:51.407
And one of the people in the
group said how about PASTA?

1139
00:53:51.407 --> 00:53:54.165
I was like, I love you,
so the veteran thought

1140
00:53:54.165 --> 00:53:57.332
of this acronym, which is PASTA, okay.

1141
00:53:59.844 --> 00:54:01.692
And then what we're
doing is we're teaching

1142
00:54:01.692 --> 00:54:04.407
all these problem-solving
skills and we're using

1143
00:54:04.407 --> 00:54:06.622
the second half of each
section to fill out

1144
00:54:06.622 --> 00:54:10.317
their safety plan, okay, and
this is what a safety plan

1145
00:54:10.317 --> 00:54:13.403
looks like, it has warning
signs, it has different strategy

1146
00:54:13.403 --> 00:54:15.705
you can do by yourself, and
when we first had the veterans

1147
00:54:15.705 --> 00:54:18.830
fill these out, they
were very, very meager.

1148
00:54:18.830 --> 00:54:22.333
They were very sparse and
what happened is they keep

1149
00:54:22.333 --> 00:54:23.969
filling them out with the new
problem-solving strategies

1150
00:54:23.969 --> 00:54:25.755
over the course of the
session so they're all working

1151
00:54:25.755 --> 00:54:29.204
on their safety plans over
time and over learning it

1152
00:54:29.204 --> 00:54:32.184
and what they had was really
beautiful safety plans

1153
00:54:32.184 --> 00:54:35.486
by the end, so we used this to facilitate

1154
00:54:35.486 --> 00:54:37.884
a shared problem-solving activity.

1155
00:54:37.884 --> 00:54:42.172
It worked pretty well and
so we did a feasibility

1156
00:54:42.172 --> 00:54:44.851
and acceptability trial,
the veterans loved it.

1157
00:54:44.851 --> 00:54:47.463
This is just satisfaction and again,

1158
00:54:47.463 --> 00:54:50.583
we did qualitative data
with it, and now we need

1159
00:54:50.583 --> 00:54:53.412
to find somebody to fund this trial.

1160
00:54:53.412 --> 00:54:56.745
Okay, so we're almost there, you've done

1161
00:54:57.962 --> 00:55:00.577
a very nice job hanging
with me, okay, these

1162
00:55:00.577 --> 00:55:04.256
are my two top things, two top
things for you to take home.

1163
00:55:04.256 --> 00:55:07.541
One is please think about
a common nomenclature.

1164
00:55:07.541 --> 00:55:09.622
We talked about this at the beginning.

1165
00:55:09.622 --> 00:55:11.591
Please think about how you're charting.

1166
00:55:11.591 --> 00:55:15.291
I know charting stinks,
I'm really bad at charting

1167
00:55:15.291 --> 00:55:17.336
but if I don't chart
well, then the next person

1168
00:55:17.336 --> 00:55:20.546
doesn't know where to start,
and so think about how

1169
00:55:20.546 --> 00:55:22.742
you're charting things and
how people can carry things

1170
00:55:22.742 --> 00:55:25.394
forward, if you're in
charge of healthcare systems

1171
00:55:25.394 --> 00:55:28.807
or bigger groups, think
about how you can implement

1172
00:55:28.807 --> 00:55:30.863
templates that actually
help people chart in a way

1173
00:55:30.863 --> 00:55:35.127
that's going to be helpful,
the VA is moving towards

1174
00:55:35.127 --> 00:55:38.292
one risk assessment for
the entire VA system

1175
00:55:38.292 --> 00:55:42.662
with this very same idea
and having one strategy

1176
00:55:42.662 --> 00:55:46.041
so that we can all talk
to each other in the VA.

1177
00:55:46.041 --> 00:55:50.208
And my next thing is that
this a social work issue.

1178
00:55:51.075 --> 00:55:55.169
TBI is a social work
issue and please be part

1179
00:55:55.169 --> 00:55:58.719
of the solution in helping
me get this message out.

1180
00:55:58.719 --> 00:56:02.861
We created this toolkit for
you all and for ourselves too

1181
00:56:02.861 --> 00:56:06.959
that helps you and us
have this information.

1182
00:56:06.959 --> 00:56:11.168
This is online, again, if you
google Rocky Mountain MIRECC

1183
00:56:11.168 --> 00:56:13.965
and you google TBI
toolkit, you'll get this.

1184
00:56:13.965 --> 00:56:16.897
It was specifically
developed for all of you.

1185
00:56:16.897 --> 00:56:20.024
It has tons of resources
in it and the resources

1186
00:56:20.024 --> 00:56:22.272
are about military and veteran culture,

1187
00:56:22.272 --> 00:56:24.273
traumatic brain injury, in general,

1188
00:56:24.273 --> 00:56:26.047
co-occurring mental health
conditions and resources,

1189
00:56:26.047 --> 00:56:27.409
in each section, there's information

1190
00:56:27.409 --> 00:56:29.555
around background, screening
assessment, intervention,

1191
00:56:29.555 --> 00:56:31.777
and resources, we tried
to put all the stuff

1192
00:56:31.777 --> 00:56:34.279
in there that's free and
that you can just get online

1193
00:56:34.279 --> 00:56:36.956
while you're sitting in clinic.

1194
00:56:36.956 --> 00:56:40.123
There's tons in there, I
didn't put tons on here today

1195
00:56:40.123 --> 00:56:41.875
for you but there's tons of resources.

1196
00:56:41.875 --> 00:56:45.844
We're actually, we got another
grant and we're now adding

1197
00:56:45.844 --> 00:56:49.288
a justice-involved section
and a pediatric section,

1198
00:56:49.288 --> 00:56:51.387
and a pediatric justice-involved section

1199
00:56:51.387 --> 00:56:54.877
so those will all be in the same toolkit.

1200
00:56:54.877 --> 00:56:58.627
Okay, and just this is
the kind of take-home.

1201
00:57:00.308 --> 00:57:02.640
What would you do, what do you
need, talk to a professional.

1202
00:57:02.640 --> 00:57:04.741
That's why you guys are
here, professionally trained

1203
00:57:04.741 --> 00:57:06.491
to deal with people with
my problems or problems

1204
00:57:06.491 --> 00:57:09.668
like I have, left to myself,
I'd probably kill myself

1205
00:57:09.668 --> 00:57:11.318
but that didn't feel right so I turned

1206
00:57:11.318 --> 00:57:14.082
towards professionals,
you guys, and to me,

1207
00:57:14.082 --> 00:57:16.457
that just means this is
like all of our work,

1208
00:57:16.457 --> 00:57:19.994
we need to do this together
and I thank you for listening.

1209
00:57:19.994 --> 00:57:22.413
A few things I'd check out,
the Rocky Mountain MIRECC

1210
00:57:22.413 --> 00:57:25.072
has a podcast, it's all around suicide

1211
00:57:25.072 --> 00:57:28.270
and suicide prevention, so
if you like to take walks

1212
00:57:28.270 --> 00:57:30.858
and listen to podcasts,
which I do, I think there's

1213
00:57:30.858 --> 00:57:32.921
really good, there's actually
a really, really good one

1214
00:57:32.921 --> 00:57:35.681
on risk assessment that
was just on recently.

1215
00:57:35.681 --> 00:57:38.673
I'm also on Twitter, who tweets?

1216
00:57:38.673 --> 00:57:42.192
Oh my lord, folks, Twitter
is the way to get tons

1217
00:57:42.192 --> 00:57:44.324
of information!
(audience chuckles)

1218
00:57:44.324 --> 00:57:47.486
Really, you guys don't
tweet for academic stuff?

1219
00:57:47.486 --> 00:57:49.822
Oh, you're so lucky you don't work for me.

1220
00:57:49.822 --> 00:57:53.185
Okay, so I hope I see you on Twitter

1221
00:57:53.185 --> 00:57:55.064
and if you are on Twitter,
then you can get lots of stuff

1222
00:57:55.064 --> 00:57:57.369
pushed to you, rather
than having to pull stuff,

1223
00:57:57.369 --> 00:57:59.633
you can get stuff pushed to
you that you're interested in.

1224
00:57:59.633 --> 00:58:01.446
So I really recommend
you getting on Twitter

1225
00:58:01.446 --> 00:58:04.743
and I thank you and I think we
have some time for questions.

1226
00:58:04.743 --> 00:58:07.743
(audience applauds)

1227
00:58:15.097 --> 00:58:15.930
Yes?

1228
00:58:17.880 --> 00:58:21.577
- [Woman] So I was wondering
how long does the window

1229
00:58:21.577 --> 00:58:24.827
(faint speaking) and--

1230
00:58:27.860 --> 00:58:29.578
- We have three months'
worth of maintenance data

1231
00:58:29.578 --> 00:58:30.836
at this point.

1232
00:58:30.836 --> 00:58:32.406
- [Woman] But not (faint
speaking) (laughs).

1233
00:58:32.406 --> 00:58:34.864
- No, no, three months, if
you're a clinical researcher,

1234
00:58:34.864 --> 00:58:37.246
three months is a great
start because sometimes

1235
00:58:37.246 --> 00:58:39.493
it's no months, and then it's super stinky

1236
00:58:39.493 --> 00:58:41.651
but the question is do
you need things to help

1237
00:58:41.651 --> 00:58:44.576
booster sessions and
things to keep it going,

1238
00:58:44.576 --> 00:58:46.045
probably yes.

1239
00:58:46.045 --> 00:58:49.127
- [Woman] And how often (faint speaking)

1240
00:58:49.127 --> 00:58:52.352
but how often (faint speaking)
veterans (faint speaking)

1241
00:58:52.352 --> 00:58:56.448
returning to (faint speaking)?

1242
00:58:56.448 --> 00:58:59.155
- So that intervention
was provided as part

1243
00:58:59.155 --> 00:59:00.969
of a clinical trial so it was outside

1244
00:59:00.969 --> 00:59:04.037
of general clinical
care but I mean I think

1245
00:59:04.037 --> 00:59:08.204
what you're getting at, maybe
I'm just gonna make it up

1246
00:59:09.782 --> 00:59:13.189
'cause I wanna say the
story so I had a veteran

1247
00:59:13.189 --> 00:59:15.789
who had a brain injury that had been

1248
00:59:15.789 --> 00:59:18.851
psychiatrically hospitalized 21 times

1249
00:59:18.851 --> 00:59:21.419
and you'd think at the
point at like at 21,

1250
00:59:21.419 --> 00:59:23.745
someone's not like
maybe I'm not picking up

1251
00:59:23.745 --> 00:59:26.293
on something here, like what am I missing

1252
00:59:26.293 --> 00:59:29.427
and I'm not that great of a
therapist but I understood

1253
00:59:29.427 --> 00:59:31.795
her history, I started working with her

1254
00:59:31.795 --> 00:59:33.892
and she hasn't been hospitalized since.

1255
00:59:33.892 --> 00:59:38.039
I mean I was a good match for
her mostly because I realized

1256
00:59:38.039 --> 00:59:42.476
she had a brain injury, and
so if you are not picking up

1257
00:59:42.476 --> 00:59:44.413
on these things, people are
going to continue to create

1258
00:59:44.413 --> 00:59:47.222
treatment plans that don't
work for people, right?

1259
00:59:47.222 --> 00:59:50.009
And so if you keep having that
happen, you might wanna think

1260
00:59:50.009 --> 00:59:52.009
what am I missing, yeah?

1261
00:59:52.876 --> 00:59:54.149
(faint speaking)

1262
00:59:54.149 --> 00:59:55.618
I'm sure it's not.

1263
00:59:55.618 --> 00:59:59.838
- [Woman] How many people
really know they have a TBI?

1264
00:59:59.838 --> 01:00:03.855
(faint speaking)
professionals like I remember

1265
01:00:03.855 --> 01:00:06.429
you saying after you have
one, but faint speaking)

1266
01:00:06.429 --> 01:00:10.122
normal that someone knows they have one?

1267
01:00:10.122 --> 01:00:12.102
(faint speaking)

1268
01:00:12.102 --> 01:00:14.779
- Okay, so this is kind
of a complicated question

1269
01:00:14.779 --> 01:00:16.255
and I didn't put specific stuff in here

1270
01:00:16.255 --> 01:00:20.422
about screening or assessment
so like if you're older

1271
01:00:21.748 --> 01:00:25.838
like me, nobody thought about
brain injury concussions,

1272
01:00:25.838 --> 01:00:29.012
so I could have people in
this room who rolled around

1273
01:00:29.012 --> 01:00:33.002
in the back of station
wagons went on family trips.

1274
01:00:33.002 --> 01:00:35.411
I mean TBI wasn't really like a thing

1275
01:00:35.411 --> 01:00:38.063
and so we're really in a
challenging place right now

1276
01:00:38.063 --> 01:00:42.001
where parents, particularly
parents who have resources

1277
01:00:42.001 --> 01:00:45.031
are overly focused on TBI (chuckles)

1278
01:00:45.031 --> 01:00:48.088
and then other folks are
under focused, right?

1279
01:00:48.088 --> 01:00:51.427
And so I'll have parents
at Children's Hospital.

1280
01:00:51.427 --> 01:00:52.973
They'll come to a clinic
there and we're doing a study

1281
01:00:52.973 --> 01:00:54.595
over there and they're super worried

1282
01:00:54.595 --> 01:00:57.237
and they're flipping out about their kid

1283
01:00:57.237 --> 01:01:00.748
having a concussion and
then we have other folks

1284
01:01:00.748 --> 01:01:04.260
who are like I've had veterans
who they're intoxicated

1285
01:01:04.260 --> 01:01:06.156
but they also get a brain injury.

1286
01:01:06.156 --> 01:01:09.183
The police think they're
intoxicated, which they are,

1287
01:01:09.183 --> 01:01:10.576
they put them in jail but
they're actually bleeding

1288
01:01:10.576 --> 01:01:12.861
into their brains at the same time, right?

1289
01:01:12.861 --> 01:01:17.525
And get very minimal rehab so
what is happening a little bit

1290
01:01:17.525 --> 01:01:20.326
that's concerning to
me and this is, again,

1291
01:01:20.326 --> 01:01:23.316
also I have specific
interest in homeless veterans

1292
01:01:23.316 --> 01:01:26.499
and homeless adults and
also incarcerated veterans.

1293
01:01:26.499 --> 01:01:29.915
In those populations, huge
numbers of individuals

1294
01:01:29.915 --> 01:01:32.926
actually have a TBI like
something like don't quote me

1295
01:01:32.926 --> 01:01:36.992
on this but well above
50%, but probably about 30%

1296
01:01:36.992 --> 01:01:40.414
have moderate to severe
injuries so but what's happening

1297
01:01:40.414 --> 01:01:43.167
a little bit is everybody's
over focusing on all the people.

1298
01:01:43.167 --> 01:01:45.247
And what I'd really like
what people to do is focus

1299
01:01:45.247 --> 01:01:47.694
on people with moderate
to severe injuries.

1300
01:01:47.694 --> 01:01:50.696
They would expect to impact
their day-to-day functioning.

1301
01:01:50.696 --> 01:01:52.461
Does that make sense, that being said,

1302
01:01:52.461 --> 01:01:54.686
there's really easy screening
questions you can ask,

1303
01:01:54.686 --> 01:01:57.130
happy to send 'em ahead,
they're also in the toolkit.

1304
01:01:57.130 --> 01:01:59.418
And I think about putting
down history of TBI

1305
01:01:59.418 --> 01:02:02.302
as part of a medical history,
a good psychosocial history

1306
01:02:02.302 --> 01:02:04.410
and also good for prevention.

1307
01:02:04.410 --> 01:02:06.396
So how many of you in here ask your folks

1308
01:02:06.396 --> 01:02:08.146
if they wear helmets?

1309
01:02:09.542 --> 01:02:13.709
I do, why not prevent, more
brain injury isn't better.

1310
01:02:16.974 --> 01:02:17.974
Right, okay.

1311
01:02:20.051 --> 01:02:21.220
Yeah?

1312
01:02:21.220 --> 01:02:23.862
- [Woman] Do you think there's
a role for family members

1313
01:02:23.862 --> 01:02:26.784
(faint speaking)?

1314
01:02:26.784 --> 01:02:28.646
- That would be great, we did
initially write it that way

1315
01:02:28.646 --> 01:02:30.152
but we were concerned
that too many veterans

1316
01:02:30.152 --> 01:02:31.568
wouldn't have family members to bring

1317
01:02:31.568 --> 01:02:33.180
so we did it without,
but I think family member

1318
01:02:33.180 --> 01:02:35.740
and family member involvement
always really helpful.

1319
01:02:35.740 --> 01:02:38.187
For the problem-solving
intervention, we definitely had

1320
01:02:38.187 --> 01:02:40.829
people go home and talk
to their family members

1321
01:02:40.829 --> 01:02:44.162
about the skills that they were learning

1322
01:02:45.168 --> 01:02:47.898
and trying to get feedback,
self-awareness is a huge problem

1323
01:02:47.898 --> 01:02:50.343
with people with moderate
to severe injuries,

1324
01:02:50.343 --> 01:02:53.786
and so it isolation, so
unfortunately, the group setting

1325
01:02:53.786 --> 01:02:57.064
is so helpful sometimes 'cause
people actually don't have

1326
01:02:57.064 --> 01:02:59.738
a lot of people in their
lives or had kinda burnt out

1327
01:02:59.738 --> 01:03:03.738
a lot of the relationships
that they have, yeah.

1328
01:03:05.610 --> 01:03:07.153
- [Woman] I have kind
of a research question.

1329
01:03:07.153 --> 01:03:07.986
- Okay.

1330
01:03:07.986 --> 01:03:09.503
- [Woman] I loved when you
were looking at the data

1331
01:03:09.503 --> 01:03:11.792
in different ways and I'm
wondering if you have a system

1332
01:03:11.792 --> 01:03:15.949
for how you do that or how
you, what you play with

1333
01:03:15.949 --> 01:03:19.001
when you start to look
at (faint speaking).

1334
01:03:19.001 --> 01:03:21.209
- I guess I don't, I should think

1335
01:03:21.209 --> 01:03:23.459
of a better answer to that.

1336
01:03:26.326 --> 01:03:28.631
No, I don't, I guess I
just try to approach it

1337
01:03:28.631 --> 01:03:30.600
from lots of different
angles and see how things

1338
01:03:30.600 --> 01:03:33.214
start to have convergence
and then if I find something

1339
01:03:33.214 --> 01:03:35.255
that doesn't have convergence, like no,

1340
01:03:35.255 --> 01:03:37.932
I need to keep looking so I
don't know if that's really

1341
01:03:37.932 --> 01:03:40.258
a system but I'm usually
not pretty satisfied.

1342
01:03:40.258 --> 01:03:43.534
I'm not satisfied till I
want more understanding.

1343
01:03:43.534 --> 01:03:47.760
Maybe that's the strategies,
keep going (chuckles).

1344
01:03:47.760 --> 01:03:49.587
Keep going, don't think you understand

1345
01:03:49.587 --> 01:03:51.159
'cause at first when
we saw that flat line,

1346
01:03:51.159 --> 01:03:53.896
I was like, I have no
idea what this means.

1347
01:03:53.896 --> 01:03:56.104
We actually, I didn't put this
in but we actually went back

1348
01:03:56.104 --> 01:03:58.694
and asked some of those
veterans what happened

1349
01:03:58.694 --> 01:04:01.228
when they were doing it
and they were just like,

1350
01:04:01.228 --> 01:04:03.904
we just gave us, we didn't try.

1351
01:04:03.904 --> 01:04:08.071
So I had to go back 'cause
I didn't understand it.

1352
01:04:08.948 --> 01:04:10.144
Yeah?

1353
01:04:10.144 --> 01:04:12.922
- [Woman] I'm wondering
about implementation

1354
01:04:12.922 --> 01:04:17.089
(faint speaking) so I
know (faint speaking)

1355
01:04:20.520 --> 01:04:24.228
so I'm wondering how
clinicians in the field

1356
01:04:24.228 --> 01:04:28.395
(faint speaking) what
kind of (faint speaking)

1357
01:04:29.403 --> 01:04:33.507
what kind of (faint speaking)
what kind of something

1358
01:04:33.507 --> 01:04:35.675
that is so (faint speaking).

1359
01:04:35.675 --> 01:04:37.453
- Yeah, well, let me actually talk

1360
01:04:37.453 --> 01:04:40.476
about something bigger
than this but the VA

1361
01:04:40.476 --> 01:04:42.518
is one of the few healthcare systems

1362
01:04:42.518 --> 01:04:45.697
that has mandated
evidence-based treatments

1363
01:04:45.697 --> 01:04:49.056
and there are specific
evidence-based treatments

1364
01:04:49.056 --> 01:04:50.682
and the evidence-based treatments are

1365
01:04:50.682 --> 01:04:54.599
'cause they actually work
and so I know we like

1366
01:04:57.102 --> 01:05:01.269
to think of ourselves as very
skilled and philosophical

1367
01:05:02.486 --> 01:05:05.412
but what I try to ask
people to think about is

1368
01:05:05.412 --> 01:05:09.579
if your family member had cancer,
would you like a therapist

1369
01:05:11.794 --> 01:05:14.640
that's very philosophical,
would you like a doctor

1370
01:05:14.640 --> 01:05:16.706
that's very philosophical
or would you like a doctor

1371
01:05:16.706 --> 01:05:20.098
that's using the best evidence?

1372
01:05:20.098 --> 01:05:23.258
You would never, ever want
to go to an oncologist

1373
01:05:23.258 --> 01:05:26.502
who says, "Well, the best
evidence says do this

1374
01:05:26.502 --> 01:05:30.652
"but I actually have my own
special way of doing it."

1375
01:05:30.652 --> 01:05:33.134
And I don't actually think
mental health is any different

1376
01:05:33.134 --> 01:05:37.385
than that, I do think the
relationship is important,

1377
01:05:37.385 --> 01:05:40.337
whether you're an
oncologist or a psychologist

1378
01:05:40.337 --> 01:05:44.529
or a social worker, the
relationship to me is the hard part

1379
01:05:44.529 --> 01:05:48.956
and using the data to
figure out how to intervene

1380
01:05:48.956 --> 01:05:52.690
but it is very, very
hard, not just in the VA,

1381
01:05:52.690 --> 01:05:56.357
but outside the VA to
have people do, adhere

1382
01:05:57.228 --> 01:05:59.995
to evidence-based interventions.

1383
01:05:59.995 --> 01:06:03.712
People, we like to think
we know better, right?

1384
01:06:03.712 --> 01:06:06.744
And I would say, I don't
know if you're familiar

1385
01:06:06.744 --> 01:06:09.351
like this is a different side deck.

1386
01:06:09.351 --> 01:06:11.146
I wish I had a (mumbles) to
show you but if you think

1387
01:06:11.146 --> 01:06:14.105
about the best cancer treatment centers,

1388
01:06:14.105 --> 01:06:16.132
I don't know what the one in Boston is,

1389
01:06:16.132 --> 01:06:18.424
like Seattle's, oh, Dana-Farber?

1390
01:06:18.424 --> 01:06:22.200
Okay, Dana-Farber, Seattle
has Fred Hutchinson,

1391
01:06:22.200 --> 01:06:23.802
is that right?

1392
01:06:23.802 --> 01:06:26.411
University of Colorado
is, Sloan Kettering,

1393
01:06:26.411 --> 01:06:28.983
I mean, any, MD Anderson,
any of the places,

1394
01:06:28.983 --> 01:06:31.957
the best oncologists are,
like if you are at the top

1395
01:06:31.957 --> 01:06:34.222
of your game, researcher,
clinician, oncologist,

1396
01:06:34.222 --> 01:06:36.193
you're at one of these places.

1397
01:06:36.193 --> 01:06:39.479
They all follow the same
protocols and they actually get

1398
01:06:39.479 --> 01:06:42.589
reimbursed more and have
a whole system together

1399
01:06:42.589 --> 01:06:45.293
of evaluating the evidence
to give their patients

1400
01:06:45.293 --> 01:06:47.539
the best protocols, the
other things that's awesome

1401
01:06:47.539 --> 01:06:50.909
about this is it doesn't matter
if you go to Sloan-Kettering

1402
01:06:50.909 --> 01:06:53.871
or Dana-Farber or Fred Hutchinson,

1403
01:06:53.871 --> 01:06:56.913
you're going to get the best treatment.

1404
01:06:56.913 --> 01:06:59.704
We are not there yet 'cause
we, I don't know why.

1405
01:06:59.704 --> 01:07:02.954
We have a special idea about ourselves.

1406
01:07:05.539 --> 01:07:07.140
It's kind of a problem,
that doesn't really answer

1407
01:07:07.140 --> 01:07:08.565
your question, right?

1408
01:07:08.565 --> 01:07:10.527
- [Woman] It does, I mean I think a lot

1409
01:07:10.527 --> 01:07:14.360
about (faint speaking) trauma

1410
01:07:16.735 --> 01:07:20.122
to the real world so I
mean (faint speaking).

1411
01:07:20.122 --> 01:07:22.862
- So one thing that we did with these,

1412
01:07:22.862 --> 01:07:24.600
so part of the challenge
is one thing we did

1413
01:07:24.600 --> 01:07:26.750
with these is we created
very specific manuals.

1414
01:07:26.750 --> 01:07:30.068
We spent tons of time on the
manuals and so the manuals have

1415
01:07:30.068 --> 01:07:33.255
like if you do these 10
things, you've done the session

1416
01:07:33.255 --> 01:07:35.285
so these would be much
easier to implement.

1417
01:07:35.285 --> 01:07:39.309
In the VA, I was saying the
VA, and I don't wanna be mean

1418
01:07:39.309 --> 01:07:41.286
to VA psychologists 'cause
VA mental health people

1419
01:07:41.286 --> 01:07:42.990
are amazing, this would
be out of the VA also,

1420
01:07:42.990 --> 01:07:45.364
but I was doing, I was
a consultant for CBT

1421
01:07:45.364 --> 01:07:48.787
for major depression so it
was totally this big thing

1422
01:07:48.787 --> 01:07:51.461
like we went to this
training, listened to these,

1423
01:07:51.461 --> 01:07:53.358
we go to this training and
then people would tape sessions

1424
01:07:53.358 --> 01:07:55.050
for six months and then
I'd listen to the sessions

1425
01:07:55.050 --> 01:07:57.102
and I'd provide feedback
and I'd listen to the tapes

1426
01:07:57.102 --> 01:07:59.719
and I'd be like, next session do this.

1427
01:07:59.719 --> 01:08:03.886
When they say this, do this,
and guess what would happen?

1428
01:08:04.927 --> 01:08:06.452
(faint speaking)

1429
01:08:06.452 --> 01:08:09.320
So guess what is in the next consultation?

1430
01:08:09.320 --> 01:08:12.447
Why, like I just told you when
they said do this, do this.

1431
01:08:12.447 --> 01:08:14.586
It's just really hard for us.

1432
01:08:14.586 --> 01:08:17.900
When I say us, I mean
people, we really like to do

1433
01:08:17.900 --> 01:08:21.342
what we like to do so I would
say early in your career

1434
01:08:21.342 --> 01:08:23.880
is the time for really good habits.

1435
01:08:23.880 --> 01:08:25.801
I try to have really good habits.

1436
01:08:25.801 --> 01:08:27.647
Sometimes I like to think I know better

1437
01:08:27.647 --> 01:08:30.320
but I really do follow protocols

1438
01:08:30.320 --> 01:08:33.302
but I have to have a
relationship with my patients,

1439
01:08:33.302 --> 01:08:36.878
they keep them coming and
good diagnostic skills.

1440
01:08:36.878 --> 01:08:40.177
That's where I think I can
be particularly helpful.

1441
01:08:40.177 --> 01:08:41.078
Yes?

1442
01:08:41.078 --> 01:08:45.245
- [Woman] I'm sorry, I'm
curious, so (faint speaking)

1443
01:08:46.255 --> 01:08:49.483
commitment, and I think a
lot about kind of discussion

1444
01:08:49.483 --> 01:08:52.324
and cultural context
and how does that matter

1445
01:08:52.324 --> 01:08:55.991
or really engaging to
have that relationship

1446
01:08:58.207 --> 01:09:02.374
with your (faint speaking)
so I'm curious how

1447
01:09:04.132 --> 01:09:08.299
(faint speaking) other identities

1448
01:09:10.365 --> 01:09:12.065
because you have (faint speaking).

1449
01:09:12.065 --> 01:09:13.223
- I do.

1450
01:09:13.223 --> 01:09:15.629
- [Woman] Have you been
able to (faint speaking)

1451
01:09:15.629 --> 01:09:18.450
through different ways
to see what really works

1452
01:09:18.450 --> 01:09:22.617
with this group (faint
speaking) gender but more--

1453
01:09:24.463 --> 01:09:27.608
- We do, so this is an
interesting question,

1454
01:09:27.608 --> 01:09:29.123
and I thought you were going
to ask something different

1455
01:09:29.123 --> 01:09:30.953
and I had a good answer for the other one

1456
01:09:30.953 --> 01:09:32.409
and now I don't have a
good answer for this.

1457
01:09:32.409 --> 01:09:33.560
(faint speaking)
Now I don't remember

1458
01:09:33.560 --> 01:09:34.650
'cause now I'm like, oh, my
gosh, that's not what I thought

1459
01:09:34.650 --> 01:09:38.285
she was gonna ask, so part
of the interesting thing

1460
01:09:38.285 --> 01:09:41.965
is in VA, we actually didn't collect a lot

1461
01:09:41.965 --> 01:09:45.715
of the diversity variables
because it's hard.

1462
01:09:49.713 --> 01:09:52.624
It's hard, it's complicated
to get people to declare

1463
01:09:52.624 --> 01:09:55.537
or not to get people to
declare, to get people to ask

1464
01:09:55.537 --> 01:09:58.633
has has been problematic so we don't have

1465
01:09:58.633 --> 01:10:01.375
that good diversity data in the charts.

1466
01:10:01.375 --> 01:10:03.739
And you could even say that
we have very binary data

1467
01:10:03.739 --> 01:10:07.067
on gender, we're getting, actually the VA,

1468
01:10:07.067 --> 01:10:09.487
if you don't know, the VA actually is one

1469
01:10:09.487 --> 01:10:13.487
of the most amazing
healthcare system for LGTBQ.

1470
01:10:14.531 --> 01:10:16.975
There's a whole policy
around it and mandates

1471
01:10:16.975 --> 01:10:20.421
and guidance and amazing
VA stuff around that.

1472
01:10:20.421 --> 01:10:22.109
So if you don't know that about the VA,

1473
01:10:22.109 --> 01:10:24.186
you gotta check out it 'cause it awesome.

1474
01:10:24.186 --> 01:10:27.420
Michael Kauth put it
in place, it's amazing.

1475
01:10:27.420 --> 01:10:29.011
Yes?

1476
01:10:29.011 --> 01:10:31.490
- [Woman] I'm just curious
about the intersection

1477
01:10:31.490 --> 01:10:35.449
of veterans who are
attempting to access services

1478
01:10:35.449 --> 01:10:38.025
who have a TBI, I guess
I would just imagine

1479
01:10:38.025 --> 01:10:41.998
that that could be a difficult
barrier to treatment,

1480
01:10:41.998 --> 01:10:46.710
having talked to some vets who
have tried to get into the VA

1481
01:10:46.710 --> 01:10:51.520
(faint speaking) and have you
ever considered researching

1482
01:10:51.520 --> 01:10:54.429
some kind of interventions for that?

1483
01:10:54.429 --> 01:10:56.806
- So, okay.
- That's a couple questions.

1484
01:10:56.806 --> 01:10:59.130
- That was a couple questions,
so let me talk about access.

1485
01:10:59.130 --> 01:11:01.352
Again, this is totally
me talking, not the VA

1486
01:11:01.352 --> 01:11:05.096
but I mean part of the reason
I show people those numbers

1487
01:11:05.096 --> 01:11:06.906
at the beginning is 'cause access

1488
01:11:06.906 --> 01:11:11.073
is like it's just really hard
and I'd say it's really hard

1489
01:11:13.012 --> 01:11:14.779
but I'd say that there's things in the VA

1490
01:11:14.779 --> 01:11:17.954
that you all and I, in
the private sector, too,

1491
01:11:17.954 --> 01:11:20.308
that the private sector
could never adhere to.

1492
01:11:20.308 --> 01:11:23.764
I mean we have same-day access
for psychiatric services

1493
01:11:23.764 --> 01:11:25.924
in the VA, I don't know
if folks can find that

1494
01:11:25.924 --> 01:11:28.264
in the community, I know in
Denver if you need to find

1495
01:11:28.264 --> 01:11:31.789
a psychiatrist in the
community, it's not same day.

1496
01:11:31.789 --> 01:11:35.634
So same-day access in the
VA, basically the deal

1497
01:11:35.634 --> 01:11:38.962
with the VA is once you're
in, people really think

1498
01:11:38.962 --> 01:11:43.238
the services are terrific, and
that's not across the board.

1499
01:11:43.238 --> 01:11:46.281
That's not, there are good
days, bad days, clinicians

1500
01:11:46.281 --> 01:11:48.211
have good days, bad days,
patients have good days,

1501
01:11:48.211 --> 01:11:49.986
bad days, but on whole, the other thing

1502
01:11:49.986 --> 01:11:53.010
that's really challenging
is oftentimes it's the VA

1503
01:11:53.010 --> 01:11:56.577
compared to nothing,
if you look at studies,

1504
01:11:56.577 --> 01:11:59.267
it's VA compared to there
is nothing to compare it to.

1505
01:11:59.267 --> 01:12:01.828
Maybe Kaiser, maybe
group health but there's

1506
01:12:01.828 --> 01:12:03.785
not a lot to compare it to,
and I'm not saying the VA

1507
01:12:03.785 --> 01:12:06.381
can't do better the VA
can always do better.

1508
01:12:06.381 --> 01:12:08.971
I've spent 20 years with the
VA doing better (chuckles).

1509
01:12:08.971 --> 01:12:11.096
I'm totally committed to VA doing better

1510
01:12:11.096 --> 01:12:14.513
but so and then just in terms of the TBI,

1511
01:12:15.752 --> 01:12:19.461
I think there is a lot
of issues around people

1512
01:12:19.461 --> 01:12:22.647
not being followed
appropriately in mental health

1513
01:12:22.647 --> 01:12:26.059
and I think some of them, if you think

1514
01:12:26.059 --> 01:12:28.577
about somebody not showing up to sessions

1515
01:12:28.577 --> 01:12:30.473
or you think about
somebody missing sessions

1516
01:12:30.473 --> 01:12:32.696
or you think about somebody
not doing homework,

1517
01:12:32.696 --> 01:12:35.024
you could interpret that as resistance

1518
01:12:35.024 --> 01:12:38.261
or you could just interpret
that as a big ole brain injury.

1519
01:12:38.261 --> 01:12:40.922
I do things in my sessions but probably,

1520
01:12:40.922 --> 01:12:43.175
if you were a very
psychodynamically oriented,

1521
01:12:43.175 --> 01:12:46.592
you would think that I am not good.

1522
01:12:46.592 --> 01:12:47.944
(audience chuckles)
I do phone calls.

1523
01:12:47.944 --> 01:12:50.372
I do reminders, I have them
call me between sessions.

1524
01:12:50.372 --> 01:12:53.862
I do all kinds of crazy
business 'cause I'm trying

1525
01:12:53.862 --> 01:12:57.735
to facilitate the treatment
and so how do you do that?

1526
01:12:57.735 --> 01:13:00.424
I know there's like more
questions in there too.

1527
01:13:00.424 --> 01:13:03.327
I'd say folks who were injured in theater

1528
01:13:03.327 --> 01:13:06.586
with a moderate to severe
TBI have very good access

1529
01:13:06.586 --> 01:13:08.551
by the way too, those
people have been tracked

1530
01:13:08.551 --> 01:13:11.718
into the system, okay, all right, yes?

1531
01:13:14.115 --> 01:13:17.056
- [Woman] Wondering you're
familiar with (faint speaking)

1532
01:13:17.056 --> 01:13:19.556
Colombia--
- I so am familiar.

1533
01:13:21.008 --> 01:13:23.758
(faint speaking)

1534
01:13:26.132 --> 01:13:27.553
Do you give it?

1535
01:13:27.553 --> 01:13:31.720
- [Woman] I think (faint speaking).

1536
01:13:33.067 --> 01:13:37.234
- Okay, so Kelly Posner is
a very strong advocate of it

1537
01:13:38.690 --> 01:13:42.202
and it has been adopted
in a number of places.

1538
01:13:42.202 --> 01:13:46.061
Okay, I'll say one thing,
so the Columbia is,

1539
01:13:46.061 --> 01:13:47.933
we've been doing some research on it.

1540
01:13:47.933 --> 01:13:49.482
There are some good
thing about the Columbia.

1541
01:13:49.482 --> 01:13:50.816
I'd say the number one not good thing

1542
01:13:50.816 --> 01:13:52.793
about the Columbia is there's
actually no treatment,

1543
01:13:52.793 --> 01:13:55.682
there's no manual for the assessment tool

1544
01:13:55.682 --> 01:13:57.567
so we've been asking
them to write a manual

1545
01:13:57.567 --> 01:13:59.894
for like five years so
I just say if you have

1546
01:13:59.894 --> 01:14:02.013
a measure without a manual, that's not

1547
01:14:02.013 --> 01:14:06.180
a great starting point,
okay, so what that results

1548
01:14:07.062 --> 01:14:10.515
in is huge variance in people giving it.

1549
01:14:10.515 --> 01:14:12.407
We use it all the time in
our studies and we have

1550
01:14:12.407 --> 01:14:14.623
a whole team, we have a smart,
what's called the smart team,

1551
01:14:14.623 --> 01:14:16.834
the measures training team
that trains people how to do it

1552
01:14:16.834 --> 01:14:20.145
but it is really hard for
people to be adherent to it.

1553
01:14:20.145 --> 01:14:22.889
Okay, and so the other
thing about the Columbia

1554
01:14:22.889 --> 01:14:27.011
is a lot of the data is on
people who are already known

1555
01:14:27.011 --> 01:14:31.249
to be at risk and so in
terms of its predictability

1556
01:14:31.249 --> 01:14:33.317
and this is probably way more
information than you wanted

1557
01:14:33.317 --> 01:14:35.958
on the Columbia, you
and I could have a drink

1558
01:14:35.958 --> 01:14:37.903
and a personal party about the Columbia,

1559
01:14:37.903 --> 01:14:41.127
so the predictive problem is
it's already people at risk

1560
01:14:41.127 --> 01:14:42.427
so we don't know how well it works

1561
01:14:42.427 --> 01:14:44.313
in terms of people who we
don't know that are at risk.

1562
01:14:44.313 --> 01:14:47.613
The other thing with it too
is it starts at a person

1563
01:14:47.613 --> 01:14:50.775
already having a challenge,
so and if you say

1564
01:14:50.775 --> 01:14:54.683
you don't have suicide
ideation, you're out, right?

1565
01:14:54.683 --> 01:14:59.445
And so it's good for getting
a suicide-related history,

1566
01:14:59.445 --> 01:15:01.525
whether it's the best
thing to assess risk,

1567
01:15:01.525 --> 01:15:04.333
I wouldn't say it's the
best thing to assess risk.

1568
01:15:04.333 --> 01:15:07.324
But if you do want to get
somebody's lifetime history,

1569
01:15:07.324 --> 01:15:10.587
I think it can be helpful
and that's probably

1570
01:15:10.587 --> 01:15:14.175
a very unsatisfying answer and
Kelly would totally disagree

1571
01:15:14.175 --> 01:15:18.342
with everything I just said,
maybe not the manual part.

1572
01:15:22.304 --> 01:15:24.186
- [Woman] Two questions, one relates

1573
01:15:24.186 --> 01:15:28.736
to the treatment protocol,
think of the risk factors,

1574
01:15:28.736 --> 01:15:32.903
of data, of (mumbles)
with TBI, plus depression,

1575
01:15:34.827 --> 01:15:37.592
suicidality, and substance
abuse, so I see how the treatment

1576
01:15:37.592 --> 01:15:42.208
interventions attune to
the thought and behavior.

1577
01:15:42.208 --> 01:15:45.513
I don't see the substance
abuse would fit in

1578
01:15:45.513 --> 01:15:48.431
(faint speaking) the rates or the risk--

1579
01:15:48.431 --> 01:15:51.478
- Right, right, I agree with that.

1580
01:15:51.478 --> 01:15:53.703
- [Woman] So that's one,
I have a second question.

1581
01:15:53.703 --> 01:15:55.234
- Can I answer that one first?

1582
01:15:55.234 --> 01:15:56.175
- What?
- Can I answer that one

1583
01:15:56.175 --> 01:15:57.483
first and then--
- Yes, and the second one--

1584
01:15:57.483 --> 01:16:00.465
- Okay, so John Corrigan has
done a lot of good research

1585
01:16:00.465 --> 01:16:02.709
around substance abuse and
TBI and it's interesting,

1586
01:16:02.709 --> 01:16:06.116
you can look at TBI amongst
those who identified,

1587
01:16:06.116 --> 01:16:08.221
I'm sorry, substance abuse
among those who identify

1588
01:16:08.221 --> 01:16:09.974
with TBI are actually if you look

1589
01:16:09.974 --> 01:16:12.106
at substance abuse
populations, a huge amount

1590
01:16:12.106 --> 01:16:15.215
of those folks also have
a TBI, same, like there's

1591
01:16:15.215 --> 01:16:18.162
big overlap with that population
and homeless population.

1592
01:16:18.162 --> 01:16:19.998
We had data, other people have data.

1593
01:16:19.998 --> 01:16:21.690
There's great data from
Canada, there's a group

1594
01:16:21.690 --> 01:16:23.826
that are looking at homelessness.

1595
01:16:23.826 --> 01:16:27.415
Folks who have TBI actually
have way worse outcomes

1596
01:16:27.415 --> 01:16:29.427
in homeless populations
than those who don't

1597
01:16:29.427 --> 01:16:32.187
so and there's, for a long
time, people were like,

1598
01:16:32.187 --> 01:16:36.241
well, if you get a TBI,
you'll stop drinking.

1599
01:16:36.241 --> 01:16:39.860
TBI does not seem to be a good
substance abuse intervention.

1600
01:16:39.860 --> 01:16:42.185
(audience laughs)

1601
01:16:42.185 --> 01:16:45.220
Obviously, right, and
so this is like a whole,

1602
01:16:45.220 --> 01:16:48.494
I would say, other area
that needs a lot of work.

1603
01:16:48.494 --> 01:16:50.315
I would check out work by John Corrigan.

1604
01:16:50.315 --> 01:16:53.474
It's excellent in this,
he's been trying to work

1605
01:16:53.474 --> 01:16:56.162
with traditional substance
abuse programs to help them

1606
01:16:56.162 --> 01:16:59.882
facilitate compensatory
strategies, and on the toolkit,

1607
01:16:59.882 --> 01:17:02.986
there's a whole section
about compensatory things

1608
01:17:02.986 --> 01:17:05.434
that you can do in the context
of evidence-based treatment

1609
01:17:05.434 --> 01:17:07.862
to make them more accessible
to people who have TBIs

1610
01:17:07.862 --> 01:17:10.640
so I encourage you to check that out.

1611
01:17:10.640 --> 01:17:13.106
And if you think about
the problem-solving,

1612
01:17:13.106 --> 01:17:15.715
I think, in particular,
hopelessness, if people drink

1613
01:17:15.715 --> 01:17:18.133
when they're feeling
hopeless or they are using it

1614
01:17:18.133 --> 01:17:20.098
because they can't think
of other interventions,

1615
01:17:20.098 --> 01:17:22.306
we have had substance abuse
come up in the context

1616
01:17:22.306 --> 01:17:26.640
of those though they are not
substance abuse interventions.

1617
01:17:26.640 --> 01:17:28.516
Do you have a second question?

1618
01:17:28.516 --> 01:17:30.504
- [Woman] Yeah, my second
question is we have a fair number

1619
01:17:30.504 --> 01:17:33.531
of our students who work in the VA and DoD

1620
01:17:33.531 --> 01:17:38.108
and very difficult cases
(faint speaking) fabulous work

1621
01:17:38.108 --> 01:17:41.788
and we always talk here
about the care provider

1622
01:17:41.788 --> 01:17:43.581
Can you talk about that?

1623
01:17:43.581 --> 01:17:46.443
When you think of the population
we're talking about here

1624
01:17:46.443 --> 01:17:50.008
TBI and then suicide, then substance abuse

1625
01:17:50.008 --> 01:17:53.539
and whatever family problems might exist,

1626
01:17:53.539 --> 01:17:57.191
how would you address the
students you work with

1627
01:17:57.191 --> 01:18:01.408
who are masters' (faint
speaking) in terms of sustaining

1628
01:18:01.408 --> 01:18:05.575
one's own sense of hope and
(mumbles) and balance any--

1629
01:18:06.423 --> 01:18:10.431
- Yes, so I'd say one thing is
just don't work in isolation.

1630
01:18:10.431 --> 01:18:15.076
Work in teams, I think most of
the VAs are working in teams

1631
01:18:15.076 --> 01:18:18.526
and do have case conferences and settings

1632
01:18:18.526 --> 01:18:20.182
where they do work with teams.

1633
01:18:20.182 --> 01:18:21.746
The other thing I'd say
is there's something

1634
01:18:21.746 --> 01:18:23.816
called the National Consult Service.

1635
01:18:23.816 --> 01:18:25.895
The National Consult Service,
I wish I had, it's on

1636
01:18:25.895 --> 01:18:29.529
the website, it's run out of
the Rocky Mountain MIRECC.

1637
01:18:29.529 --> 01:18:32.210
Any person that works in the
VA system that has a case

1638
01:18:32.210 --> 01:18:34.370
that they're concerned about
and actually pretty soon,

1639
01:18:34.370 --> 01:18:36.546
any person not in the
VA system, any person,

1640
01:18:36.546 --> 01:18:39.343
can put in a consult and
you can get consultation

1641
01:18:39.343 --> 01:18:42.661
with experts around how to
deal with really hard cases.

1642
01:18:42.661 --> 01:18:45.421
And so I'd say don't deal with this alone.

1643
01:18:45.421 --> 01:18:47.531
If you have cases that
are really contributing

1644
01:18:47.531 --> 01:18:50.489
to you worrying, don't worry
alone, get consultation,

1645
01:18:50.489 --> 01:18:52.467
either from supervisors, from teams

1646
01:18:52.467 --> 01:18:55.534
or from National Consult Service.

1647
01:18:55.534 --> 01:18:58.527
And I think just talking
about it too and just saying,

1648
01:18:58.527 --> 01:19:02.655
like being willing to say
when we were doing the study

1649
01:19:02.655 --> 01:19:06.807
for Carson, we were actually
interviewing guys and gals

1650
01:19:06.807 --> 01:19:11.565
as they got off the airplane
and we did like hundreds

1651
01:19:11.565 --> 01:19:14.830
of interviews, and I'm pretty okay usually

1652
01:19:14.830 --> 01:19:16.831
and I was watching a
movie and all of a sudden,

1653
01:19:16.831 --> 01:19:19.190
I started having all
these intrusive thoughts.

1654
01:19:19.190 --> 01:19:21.776
And I was like (chuckles)
oh my gosh, there it is,

1655
01:19:21.776 --> 01:19:25.241
like I'm not okay, and so I
think in another big thing

1656
01:19:25.241 --> 01:19:29.137
is like it's okay, it's okay
to not be okay sometimes.

1657
01:19:29.137 --> 01:19:31.657
It's okay to get help, it's
okay to take a step back.

1658
01:19:31.657 --> 01:19:33.072
It's okay to do all those things.

1659
01:19:33.072 --> 01:19:36.290
And so certainly we need
the VA to do that together.

1660
01:19:36.290 --> 01:19:37.842
The other thing, there is actually this

1661
01:19:37.842 --> 01:19:40.441
is more of an interesting
(mumbles) in your idea.

1662
01:19:40.441 --> 01:19:42.395
There's an app, the VA
has a bunch of apps.

1663
01:19:42.395 --> 01:19:45.330
There's actually a
self-help app for providers.

1664
01:19:45.330 --> 01:19:47.581
I don't know if people have seen that

1665
01:19:47.581 --> 01:19:51.202
so I mean I think all these
things are all small pieces

1666
01:19:51.202 --> 01:19:54.609
that consultation, working
in teams, self-help,

1667
01:19:54.609 --> 01:19:56.953
taking care of yourself, taking vacations.

1668
01:19:56.953 --> 01:19:59.749
I'm not very good at that
one, but all these things

1669
01:19:59.749 --> 01:20:03.429
that you need to do,
and I think it's hard.

1670
01:20:03.429 --> 01:20:06.073
And I think we, unfortunately,
are burning out people

1671
01:20:06.073 --> 01:20:09.490
at a high rate, and I'm open to any ideas

1672
01:20:11.375 --> 01:20:12.859
about how to do that.

1673
01:20:12.859 --> 01:20:14.410
You know, the interesting
thing, they're actually doing

1674
01:20:14.410 --> 01:20:16.849
a lot of interesting
work on the crisis lines

1675
01:20:16.849 --> 01:20:20.682
to do more self-care
stuff, the VA crisis line

1676
01:20:22.205 --> 01:20:24.097
so I'm happy to talk
about that another time.

1677
01:20:24.097 --> 01:20:26.988
It's very interesting, yes?

1678
01:20:26.988 --> 01:20:29.077
- [Man] I'm sorry, but
I got stuck on something

1679
01:20:29.077 --> 01:20:33.567
that you (faint speaking)
when you were answering

1680
01:20:33.567 --> 01:20:35.671
her first question.
- Okay.

1681
01:20:35.671 --> 01:20:38.166
- [Man] About hopelessness
and drinking when

1682
01:20:38.166 --> 01:20:39.999
you're hopeless.
- Yes.

1683
01:20:45.376 --> 01:20:47.964
- [Man] How about self-medicating
instead of being hopeless?

1684
01:20:47.964 --> 01:20:48.797
- Totally.

1685
01:20:50.321 --> 01:20:51.946
- [Man] I mean I've been there.

1686
01:20:51.946 --> 01:20:52.779
- Yes.

1687
01:20:52.779 --> 01:20:55.265
- [Man] And that was my
experience of hopelessness.

1688
01:20:55.265 --> 01:20:59.143
It was always alcohol
makes things go away.

1689
01:20:59.143 --> 01:21:01.535
- Absolutely, I mean there's
many, many different reasons

1690
01:21:01.535 --> 01:21:04.243
and if it's chicken or
egg, right, and so if it's

1691
01:21:04.243 --> 01:21:06.997
chronic pain that we're
not treating sufficiently,

1692
01:21:06.997 --> 01:21:09.781
if it's sleeplessness that
we're not treating sufficiently,

1693
01:21:09.781 --> 01:21:13.447
there's many things that
contribute to substance use

1694
01:21:13.447 --> 01:21:16.934
and substance use can provide
short-term relief for people,

1695
01:21:16.934 --> 01:21:18.020
right, and so--

1696
01:21:18.020 --> 01:21:19.831
- [Man] Those short-term
solutions are long term--

1697
01:21:19.831 --> 01:21:23.542
- Yes, but sometimes it is
right there, right, and it can--

1698
01:21:23.542 --> 01:21:24.809
- [Man] It works.

1699
01:21:24.809 --> 01:21:27.780
- It can work in the short
term and so the question

1700
01:21:27.780 --> 01:21:30.210
is how do we help people
have other alternatives.

1701
01:21:30.210 --> 01:21:33.880
And none of that addresses
the biological underpinnings

1702
01:21:33.880 --> 01:21:38.047
of addiction that is a different,
very problematic thing.

1703
01:21:39.068 --> 01:21:42.529
And how do we have AA and all
the other things that we know

1704
01:21:42.529 --> 01:21:44.749
that work that actually address
people's cognitive problems

1705
01:21:44.749 --> 01:21:47.166
and help people stay engaged?

1706
01:21:48.797 --> 01:21:50.547
But I agree with you.

1707
01:21:54.856 --> 01:21:58.335
- [Man] The group of veterans
in the circles I travel in--

1708
01:21:58.335 --> 01:21:59.168
- Yeah.

1709
01:22:00.264 --> 01:22:04.199
- [Man] Most are frustrated
with the psychopharmacological

1710
01:22:04.199 --> 01:22:05.297
solution.
- I completely agree.

1711
01:22:05.297 --> 01:22:06.869
- [Man] And again, why they go to alcohol

1712
01:22:06.869 --> 01:22:10.253
because they what the effect
is but (faint speaking)

1713
01:22:10.253 --> 01:22:12.743
becoming a problem when they
can't, that's their only go-to.

1714
01:22:12.743 --> 01:22:16.279
- Yes, and I think
psychopharm is a huge problem

1715
01:22:16.279 --> 01:22:19.014
so I could not agree more with you.

1716
01:22:19.014 --> 01:22:21.705
We need to be looking at
other ways to help people

1717
01:22:21.705 --> 01:22:24.869
so I mean I'm not talking
about any of this here.

1718
01:22:24.869 --> 01:22:28.019
I finally got a yoga trial
for post-concussive headaches

1719
01:22:28.019 --> 01:22:32.504
funded after seven times in
but so there are other things

1720
01:22:32.504 --> 01:22:35.378
that we need to study, I
also have a probiotics trial

1721
01:22:35.378 --> 01:22:39.242
for stress, so yes, we need
to be looking at other things.

1722
01:22:39.242 --> 01:22:40.622
I could not agree with you more more.

1723
01:22:40.622 --> 01:22:42.668
That's not in any of my lecture today

1724
01:22:42.668 --> 01:22:45.508
but you are totally on track,
medications are not the answer

1725
01:22:45.508 --> 01:22:49.675
for everybody and sometimes
medications work great.

1726
01:22:50.753 --> 01:22:51.586
Okay, yes.

1727
01:22:53.624 --> 01:22:54.457
Last one.

1728
01:22:56.066 --> 01:22:59.861
- [Man] Roughly slightly
less than half of veterans

1729
01:22:59.861 --> 01:23:02.035
choose not to be treated at the VA system.

1730
01:23:02.035 --> 01:23:02.914
- Okay.

1731
01:23:02.914 --> 01:23:06.108
- [Man] Which puts the
responsibility for TBI

1732
01:23:06.108 --> 01:23:09.584
addictions, all those things
in civilian healthcare

1733
01:23:09.584 --> 01:23:13.751
provider community, do you
have, in your toolkit here

1734
01:23:15.859 --> 01:23:20.196
resources for translating
this kind of highly detailed

1735
01:23:20.196 --> 01:23:24.363
submission into the clinical
work that a family practitioner

1736
01:23:25.281 --> 01:23:28.364
or a GP or a pediatrician, and if so,

1737
01:23:30.433 --> 01:23:32.046
what's the sources for that?

1738
01:23:32.046 --> 01:23:34.593
- There's tons of different
sources for the information

1739
01:23:34.593 --> 01:23:37.760
that's in there, what I would
love it if you would look at

1740
01:23:37.760 --> 01:23:40.608
it and tell me if you think I do or not

1741
01:23:40.608 --> 01:23:43.668
'cause if I don't, I need
to add more things in.

1742
01:23:43.668 --> 01:23:47.570
- [Man] And so you would
suggest the (mumbles) .gov?

1743
01:23:47.570 --> 01:23:51.210
- Yeah, yeah, I don't
think I can go back, yeah.

1744
01:23:51.210 --> 01:23:53.346
I'm sorry I didn't put in
more about the toolkit here

1745
01:23:53.346 --> 01:23:56.419
but yeah, I would love,
and if there's stuff

1746
01:23:56.419 --> 01:23:57.867
that you're like why isn't this in here?

1747
01:23:57.867 --> 01:23:59.351
It's so obvious, then you should tell me

1748
01:23:59.351 --> 01:24:01.961
and we'll put it in, it's
like a living toolkit though.

1749
01:24:01.961 --> 01:24:03.503
Also, do people know about the crisis line

1750
01:24:03.503 --> 01:24:05.249
and the chat line, no?

1751
01:24:05.249 --> 01:24:08.932
Okay, veterans' crisis line 24 hour a day,

1752
01:24:08.932 --> 01:24:11.692
VA provider staffed,
they can see VA charts

1753
01:24:11.692 --> 01:24:14.600
if veterans will let
them, same with chat line.

1754
01:24:14.600 --> 01:24:17.165
Amazing, amazing
individuals that work there.

1755
01:24:17.165 --> 01:24:19.294
Unbelievable, I was there for
their clinical advisory board

1756
01:24:19.294 --> 01:24:22.443
last week, two weeks
ago, amazing resource.

1757
01:24:22.443 --> 01:24:26.528
I mean VA has some amazing
resources that if you don't know,

1758
01:24:26.528 --> 01:24:28.836
you should check 'em out, all right?

1759
01:24:28.836 --> 01:24:30.669
Thank you all so much, I know it's late.

1760
01:24:30.669 --> 01:24:33.669
(audience applauds)