During an undergraduate semester abroad in London, Dr. Matthew K. Nock worked in a psychiatric hospital where he was exposed to patients who had been hospitalized due to severe self-injury. He says, “Some of the patients had cut their arms, one had pulled out an eyeball, and another who I became quite close to ended up dying by suicide. I saw people’s lives affected by self-injurious thoughts and behaviors in terms of impairing their ability to function, causing distress and concern to those around them, and in the most extreme case, ending their own lives.”
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Since then, Dr. Nock went on to obtain more than 20 years of experience in self-injury and suicide research to help improve the way that clinicians identify those at risk, monitor that risk, and better prevent these thoughts and behaviors before they occur. He received his PhD from Yale University in 2003 and now teaches at Harvard University (MA).
Dr. Nock has received multiple awards from the American Psychological Association, the Association for Behavioral and Cognitive Therapies, and the American Association of Suicidology. Funding for his research has been made available through the National Institutes of Health and several private foundations. Perhaps most notably, he received a MacArthur Fellowship in 2011, which is a $500,000, no-strings attached grant for individuals who have shown extraordinary ingenuity in their work and promise to do more.
According to Dr. Nock, “I was going to work one day when I got a phone call, and the person on the other end of the line asked me, ‘Do you know anyone who has ever won a MacArthur Fellowship?’ I said no, so he said, ‘Well, you do now. You are one of this year’s awardees.’ It was an amazing experience. More than anything else, I was excited at the exposure and recognition that this brought to suicide research, which has been wonderful. I think it has allowed us to do more experimental work and take risks that we wouldn’t have been able to take otherwise. Not a lot of clinical psychologists have received a MacArthur Fellowship, so it was also nice to have clinical psychology recognized in that way.”
Are Suicide Rates on the Rise?
Despite what you might have been led to believe by the media, according to Dr. Nock, suicide rates in the United States haven’t really gotten worse when you look at the big picture (e.g., from 1900 and 2000). However, rates for suicide haven’t gotten better either.
As Dr. Nock explains, “The rates of suicide overall have increased in the last 10 years. However, they decreased in the 10 years before that, so it seems that there is always a bit of an ebb and flow. Although suicide is a leading cause of death, it is a fairly low base-rate behavior. There are 40,000 suicide deaths each year in the United States, and when you break that number down into groups such as middle-age men and older women, you will see more variability from year to year because these are smaller groups. Each year, some groups go down and some go up, but if you take a longer view, the rates have been pretty stable.”
In regard to rates of self-injury, he and other researchers are less certain, partially because of a lack of longitudinal data on the issue. “Only in the last 10 or 20 years did researchers and others start to look at nonsuicidal self-injury in a systematic way. Anecdotally, self-harm seems to be certainly on the rise. For example, many teachers and clinicians say that they didn’t see anybody engaging in self-injury 20 years ago; now, we see estimates suggesting that 10 to 20% of high school students engage in these acts. Thus, we think it is rising, but there aren’t good data to document that yet.”
Advancements in Research
One of the challenges of conducting self-harm and suicide research and preventions is that people often intentionally hide their thoughts of suicide or their intent to hurt themselves for a number of reasons. As Dr. Nock explains, “I think there is still unfortunately a lot of stigma around the experience of self-injurious thoughts and behaviors, so people sometimes fear how others are going to respond. I have often heard of a concern that, if you are a student, it could negatively affect your academic standing. It could harm relationships. It could lead to loss of standing at work or on an athletic team and so on. I think there is always a concern that you might be locked in a hospital against your will and have your rights and privileges taken away from you. Thus, many people don’t tell anyone about these thoughts because they think there is going to be a negative reaction from others and that they can handle it on their own.”
In response, Dr. Nock and other researchers have tried to develop better ways to detect suicidal thinking and predict suicide behavior. Their research has included using behavioral tests such as the Implicit Association Test (IAT), the emotional Stroop test, and others to ask people to respond to self-injury and suicide-related stimuli to try to measure how they are thinking about suicide.
For example, the IAT is a well-known test developed by Dr. Anthony Greenwald and colleagues in the area of social psychology to measure how people think about other groups, their own groups, how people think about men versus women, old versus young, and people of different races. Dr. Nock says, “We modified this test to measure how people think about self-injury or suicide by having participants classify, for instance, suicide-related words or life-related words, as well as self-related words and other-related words. What we hypothesized and found is that those who are quicker to sort words when suicide- and me-related words are paired to the same side of the computer screen are at significantly increased risk for future suicidal behavior. Performance on this test actually helps to predict suicide attempts over the next few months above and beyond patients’ own predictions, above and beyond clinician predictions, and above and beyond other risk factors.”
“We have also been doing studies increasingly out in ‘the wild’ or the real world,” Dr. Nock adds before explaining some of the reasons why this has proven to be essential to his research. “One reason is that self-injurious thoughts typically happen out in the world. Not in the lab. We can’t ethically try to make people self-injurious or suicidal in the lab to study the phenomena of interest. Instead, we have to go out into the world to emergency departments and psychiatric inpatient units to study people who are currently suicidal using real-time monitoring such as smart phones and biosensors.”
Dr. Nock believes that this has provided better information about what these thoughts look like in the real world and has also highlighted just how difficult this problem is to study. “These are fairly low base-rate behaviors, so we don’t know when in time and place that they are going to occur, and it is going to be transient in nature. When people have suicidal thoughts, this will typically last a few days or weeks, and so it is difficult to identify people at risk, capture their thoughts and behaviors, and study their influences in the real world.”
Looking to the Future
According to Dr. Nock, a big push of his research moving forward will be going out into real clinical and school settings to see how he can apply what he has learned in the lab to improve clinical care on the frontline. “We will continue to try to advance our understanding of suicide and self-harm, and attempt to push the field in directions it hasn’t gone in before. We are doing everything from working with large samples of people to trying to understand some of the subtleties of suicide behaviors in terms of risk and protective factors. We are continuing to do lab-based work to understand what kind of psychological processes drive these behaviors. And as I said earlier, we are increasingly going out into the field to use new technology to understand how these behaviors unfold in real-time to get better at prediction and prevention in ways that can be used by clinicians to have a real impact on people’s lives.”
“I am also hopeful that some of the students reading this will be motivated to study this area because they are needed. There is a lot that we don’t know about suicide and self-injury. This is such an important problem, and there aren’t enough people studying it.” In terms of room for advancement and improvement, Dr. Nock believes that one of the most exciting areas where younger researchers will have a special advantage is through the explosion of new technologies that are often best understood by the younger people who are using them. “For example, the use of smartphones, iPads, and social media platforms can really help us understand people and what influences them in a way that we have never been able to do before. Its opens up opportunities for new interventions in terms of pushing out interventions to people’s electronic devices. There is a new world of possibilities that could improve our ability to understand, predict, and prevent.”
Advice for Students
For students interested in pursuing a career in self-injury and suicide research, consider whether you have the particular characteristics that Dr. Nock seeks for passionate researchers in his own lab. He says, “We want people who care deeply about what they are studying and who are passionate about improving our understanding and ability to predict and prevent these outcomes. We also want people who are nice, very hardworking, and interested in making sure that research is conducted in the right way. Research is often extremely tedious and time-consuming work; we want people who are really passionate and dedicated so that it gets done in the best way possible.”
To practice these skills, Dr. Nock encourages anyone interested in research to take content courses like Intro to Psychology and also to build a strong understanding in Research Methods and Statistics, which he says were some of the most important courses that he took for his own research as an undergraduate and graduate student. He also believes that “there is no substitute for experience, so I would encourage students to get as much research experience and clinical research experience as they can.”
“Work broadly too,” he says. For example, in his own training, he worked with epidemiologists, experimental psychopathologists, and treatment researchers. “It takes a real funnel approach, so get really broad experience early on to see what you are interested and excited about, and only after doing lots of different things, narrow into one given area.”
This funnel approach has enabled him to obtain a wide range of perspectives from his many mentors who have taken very different approaches to academia, research, and practice. He says, “I’ve been fortunate to have a number of outstanding mentors over the course of my career such as Dr. Peter Marzuk, who is a psychiatrist at Cornell Medical School. During graduate school, I was fortunate to work with Drs. Alan Kazdin, Mitch Prinstein, and others. They have remained hugely influential mentors throughout my career up to this day. Even now as a faculty person, I have senior faculty who I look up to as mentors who have helped to guide the course of my career. I think probably the most important thing that one can do in terms of training is to identify a really good, strong mentor who is able to teach you how to think, do research, analyze your data, and ask important research questions.”
Ask an Expert
How can you recognize someone who is considering or has attempted self-injury or suicide?
“I think that the simplest and probably the best advice I can give is this: If you think someone might be at risk of suicidal behavior or making a suicide attempt, simply ask them. We know that about two thirds of people who die by suicide told someone ahead of time that they were thinking about death, wanting to be dead, or about suicide. Of course, most people who are thinking about suicide will never go on to make a suicide attempt, but if someone is thinking about it, or if you think they are thinking about it, always ask them.”
What should you say to this person?
“Whether the person says that they have been feeling depressed or thinking about death, I would recommend saying, ‘Hey, I am concerned for your safety, are you thinking about suicide?” Just ask them, straightaway. If they are not, they won’t typically be offended by this. If they are, sometimes they will share that information with you. Then, I would just suggest responding in a calm, but concerned, way. Do your best to get them to talk to a professional about what they are experiencing, whether that be talking to their clinician if they have one, going to their university’s health center, talking to a resident assistant, or calling a hotline. Do whatever you can to get that person to talk to a professional so that they can get a formal evaluation and get into treatment if needed.”
What should you avoid?
“Don’t ignore someone talking about suicide, don’t dismiss it, and don’t joke about it. I think this is a way to miss an opportunity to give someone help who needs it and who might be expressing, even subtly, a desire to let others know what they are thinking and to get help. If you sense or hear that someone is thinking about suicide, again I would just ask them straightaway and then do whatever you can to get them help.”
Matthew K. Nock, PhD, is a professor in the Department of Psychology at Harvard University, MA. Dr. Nock received his PhD in psychology from Yale University, CT (2003), and completed his clinical internship at Bellevue Hospital and the New York University Child Study Center (2003). His work, funded by grants from the National Institutes of Health, Department of Defense, U.S. Army, and private foundations, has been published in more than 100 scientific papers and book chapters. Dr. Nock’s work has been recognized through the receipt of four early career awards from the American Psychological Association, the Association for Behavioral and Cognitive Therapies, and the American Association of Suicidology; and in 2011, he received a MacArthur Fellowship (aka “Genius Grant”). At Harvard, Dr. Nock teaches courses on statistics, research methods, self-destructive behaviors, developmental psychopathology, and cultural diversity—for which he has received several teaching awards including the Roslyn Abramson Teaching Award and the Petra Shattuck Prize.
Copyright 2016 (Volume 20, Issue 2) by Psi Chi, the
International Honor Society in Psychology
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