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“Research Ethics Reimagined” is a podcast created by Public Responsibility in Medicine and Research (PRIM&R), hosted by Ivy R. Tillman, PRIM&R's executive director. Here, we talk with scientists, researchers, bioethicists and some of the leading minds exploring new frontiers of science. This season, we are going examine research ethics in the 21st century -- and learn why it matters to you.
Welcome to Research Ethics Reimagined, a podcast from Public Responsibility in Medicine and Research, where we explore the ethical, regulatory, and human dimensions of research in a rapidly evolving scientific landscape. I'm Catherine Batford, co-host of today's episode, and I'm joined by my colleague and co-host, Tonya Ferraro. In this episode, we're pleased to welcome Matthew Nock, PhD, the Edgar Pierce Professor of Psychology at Harvard University and former chair of the Department of Psychology. Dr. Knock is a leading expert in the study of suicide and self harm, and his research has significantly shaped how the field understands risk, prediction, and prevention of suicidal behavior.
Catherine Batsford:So just to get us started, can you share a little bit about your journey in psychology and initially what drew you to this focus of research?
Matthew K. Nock, Ph.D.:Absolutely. And I want to start off by saying thank you so much for having me on and thanks, Catherine and Tonya, for this conversation. I'm a professor, so I could talk for hours. So I'll try and keep myself brief. I got interested in the study of suicide just by sort of happenstance.
Matthew K. Nock, Ph.D.:I was an undergraduate at Boston University, and I did a semester abroad in London. And as part of our academic experience there, they placed us in different internships. So one student worked in the Guinness Brewery and one student worked for a record company. I ended up getting a placement in a psychiatric hospital. And there was a unit in that hospital that had violent and self injurious patients.
Matthew K. Nock, Ph.D.:And so I was placed there. And I was just really taken aback by the clinical severity of a lot of the behaviors that I saw. There was violence and I had seen that before in my life as a college student. But the self injury, people cutting themselves, burning themselves, trying to kill themselves, struck me as being very severe, very perplexing. I didn't really understand it.
Matthew K. Nock, Ph.D.:I wanted to be a practicing clinician at the time. And so I thought, Let me learn about what seems to me the deep end of the clinical pool. If I can understand how to effectively treat people who are self injurious and suicidal, the other things I might encounter, depression, anxiety, and so on, should be easier. And I just never got out of it. I started doing research on suicide as a postbac and learned how little we know about suicide.
Matthew K. Nock, Ph.D.:And it's such a big problem. It is a leading cause of death in The US and around the world. It's the second leading cause of death among those ages 10 to 34 years behind only accidents. Suicide takes more life than all violence, all wars, genocide, interpersonal violence, murder combined. So around the globe, we're each more likely to die by our own hand than we are by someone else's.
Matthew K. Nock, Ph.D.:But we hear in the news and in our daily lives a lot more about violence and about murder and about cancer and other forms of death. We don't talk a lot about suicide, and there's not, relatively speaking, not a lot of research on suicide, not nearly as much as there should be. So over the years, I became very interested in the topic. As I saw, there wasn't a lot of research. Certainly when I started, twenty something years ago, there's now more.
Matthew K. Nock, Ph.D.:There's an increasing amount of research on suicide. But that's how I got into the topic. I sort of just came upon suicidal self injurious behavior in an academic clinical rotation, started studying it and sort of never got out. Wow.
Catherine Batsford:It is such a taboo subject. It really
Matthew K. Nock, Ph.D.:Yeah. Society It's something that it's often a conversation stopper, on airplanes, at parties. If I say I'm a psychologist, people will, what does it mean that I like the color blue? All kinds of interesting little tidbits. But when I talk about I study suicide self injury, most of the time people pause and sort of put their head down and look to the passenger on the other side of them on airplane.
Matthew K. Nock, Ph.D.:I think that's part of the problem, we don't It is taboo, it's mysterious, people are concerned, and this gets a little bit into some IRB concerns. People are concerned that if we talk about it, if we focus on it, perhaps it's gonna make things worse, it's gonna give people the idea. People are afraid as in a lot of instances of death, are afraid to say the wrong thing. They don't know what to do. And so we tend to get really nervous as a society, as people, and clam up.
Matthew K. Nock, Ph.D.:So it's a challenging topic. I'm really glad that you're covering it. It's one that from an IRB perspective has been challenging. Right. Because a lot of these concerns, you know, IRBs are designed, intended, focused on protecting human subjects, not increasing risks.
Matthew K. Nock, Ph.D.:So naturally, those serving on IRBs do have a lot of questions about suicide and self injury and are the methods we're using to try and better understand this topic, these thoughts, these behaviors, are we inadvertently making things worse? So I think it's important for our, as a researcher, our partners on the IRB have a good understanding of what we've been learning over the past few decades and where the science is. And this is partly how I got into You didn't mention in your intro, one of my proudest lines in my CV is I was a chair of the Harvard IRB for six years and got to work with Tonya there and other wonderful people in the Harvard IRB community. I initially got into working on IRBs when I was a graduate student and I was doing research on suicide and I did my PhD at Yale and the IRB had a lot of questions about the study I was doing. They called me in and were asking me questions and it led to them saying, Why don't you join the IRB?
Matthew K. Nock, Ph.D.:And I joined the Yale IRB, the medical school IRB, as a graduate student and really loved it. It opened up a lot of questions for me about the nature of the work we do and what's helpful and what's harmful and what should we be mindful of and what experiments should we build in so we can test whether we're harming people with the methods we're using and so on. And that carried on into my faculty position. After doing my PhD, I started working at Harvard in the psychology department, joined the IRB and then became chair in 2010, I think it was, and did that for a number of years and have kept in close contact with the IRB at Harvard. And we also do a lot of work in hospitals.
Matthew K. Nock, Ph.D.:Harvard affiliated hospitals typically will refine people who are actively, acutely suicidal who are often in hospitals. And so a lot of our studies bridge across arts and sciences and medical schools. So there's often multiple IRBs involved, which also introduces some complexity Sorry to for the ramble and happy to thank you. No.
Tonya Ferraro:So that actually is a great segue in that when I was a research project manager, I told my PI that I wanted to work for an IRB learn about the process from the inside out. He said, so you're going to the dark side. And then I met you and when you're in the chair and I have this distinct memory of you literally rolling up your sleeves and saying, Okay, how can we approve this study? And I just love the tone you set. And I'm curious, as you work as a chair, how can IRBs and researchers build trust and work as collaborators?
Matthew K. Nock, Ph.D.:Yeah, thank you for the positive comment. As researchers, we don't get a lot of them. It's a must of rejection. I think openness, transparency, collaboration, not seeing each other as the dark side is a good start. Attributing there's an idea in psychology called the hostile attribution bias, where you attribute hostile intent to others.
Matthew K. Nock, Ph.D.:And the classic example is you're a fifth grader, you're in the cafeteria, someone spills milk on you. Do you assume they did it on purpose because they're trying to harm you in some way? Or do you say, Oh, it must have been an accident. I think this is an important concept for researchers working with IRBs. IRBs often, in my experience, aren't trying to harm researchers, aren't trying to stop us from doing the work we want to do, but instead protecting human subjects.
Matthew K. Nock, Ph.D.:So how can we work together collaboratively? And I'm grateful that you attribute that sentiment to me as IRB chair. Let's figure out a way to approve this. I always saw the Harvard IRB having that stance, which I always really appreciated. As a suicide researcher, I hear from a lot of colleagues who say, When I say I'm studying suicide, my IRB says, We can't allow that.
Matthew K. Nock, Ph.D.:You can't do that work here. And I've always appreciated when IRBs have the stance of, How can you do this work? How can we help you figure out how to ask the questions you want to ask in a way that's ethically sound and doesn't increase harm to participants? So I tried to carry that on in my work as IRB Chair. But I think from where I sit and from my experience, just having that collaborative, transparent, open, can do spirit goes a really, really long way.
Matthew K. Nock, Ph.D.:And being flexible. As a researcher, could say, Well, here's what I want to do. There are concerns that IRBs have or that I haven't thought through fully and the IRB helps me think through them, wonderful. And one common one that comes up is a research issue, but it's also a clinical issue. If folks take anything from this podcast, I hope there's something that clinically, interpersonal people can take.
Matthew K. Nock, Ph.D.:Asking other people about suicide, does that increase their likelihood of thinking about suicide? It's a really good question, and it's one that most IRBs have, a lot of people have. If I ask my kid, I if ask my spouse, if I ask my sibling, if they're thinking about suicide, is that going to make things worse? There are now multiple experiments demonstrating pretty clearly it is not harmful to ask people about suicide. There are randomized controlled trials.
Matthew K. Nock, Ph.D.:There are experiments. Some people get asked about suicide, some people don't. Asking the question, Are you having thoughts of suicide? Does not increase the stress. It does not make people be more likely to have suicidal thoughts, does not increase risk of suicidal behavior.
Matthew K. Nock, Ph.D.:So this is the kind of thing that comes from healthy interactions between researchers and institutional review boards. A question gets asked repeatedly, we should go and study it and see, does the method we're using increase harm in some way that we didn't anticipate? And that point, I think, is an important one, again, for us all as humans, as we walk around. It's okay if you think someone you know might be having thoughts of suicide, it is not harmful on average to ask them if they're having thoughts of suicide. And in my two and a half decades of doing this work research wise and as a licensed clinician, I can't remember a time where asking the question really harm people, harm the person in some way.
Catherine Batsford:So it's a delicate balance between collecting the meaningful data, going through the taboos to get people to start to talk and to educate the IRB at the same time that, there is data behind this, that it's not harmful and that we can ask the difficult questions.
Matthew K. Nock, Ph.D.:Yeah. Think it Yeah. And requires flexibility on the side of the researcher to say, as I was just saying, asking people about suicide does not increase harm overall. The studies that have been done look at group averages. We do research where we use behavioral tests, like the implicit association test, where we show people images or words that are of the type death, suicide.
Matthew K. Nock, Ph.D.:We might include stimuli that are pill bottles or nooses just to symbolize suicide. And we show these repeatedly, dozens of times. The reason we do this is, in short, people's response times to these kinds of images, I'll cartoon defining a little bit, in milliseconds tells us who's at risk for a suicide attempt above and beyond what people self report does. So there's some important research finding here. There's clinical import here.
Matthew K. Nock, Ph.D.:A question that gets asked by IRBs, does showing people pictures of pill bottles and uses dozens of times, does that make people more distressed? So we did several experiments where and the data showed, these images does not increase significantly people's distress, thoughts of suicide, thoughts of death. But in some individual cases, people do say, I really didn't like that. I found that really distressing. So now in our consent forms, we say, On average, this does not increase risk.
Matthew K. Nock, Ph.D.:We expect that it won't But there are some instances, some people do experience some distress from this. And if you do, you can stop at any time. So it's a back and forth. We do experiments, but we also have to remain open and transparent and honest about the fact that these experiments are based on group averages, and some individuals may experience distress, so we work that in. So I see this as an iterative process.
Matthew K. Nock, Ph.D.:As research is iterative, interactions with IRBs and participants, I think we have to expect are going be iterative as well, we have to be flexible over time.
Tonya Ferraro:During your keynote, you brought up the concept of this is an empirical question. I know one of the things I love about research is that data can tell a very different story and challenge what may feel intuitively true to someone. So what other findings maybe have surprised you or that surprised the IRB as you've presented it to them?
Matthew K. Nock, Ph.D.:It's a great question and a great sentiment. There's an old scholar, W. Edwards Deming, who had this great quote that I love. He said, In God we trust, all others must bring data. Because we can have trust in institutions and authority and higher powers and so on, but ultimately many of these questions are empirical.
Matthew K. Nock, Ph.D.:And we can all have opinions, we can all have beliefs about them. But ultimately, what do the data say? And I think we have to keep our, as researchers, our humility and the questions that we're asking are largely empirical. And this is what drew me to science, that I was a very oppositional kid. And so I love that questioning is encouraged in science, And there's a system for evaluating what the truth is and what the data show.
Matthew K. Nock, Ph.D.:And so I think we all have to remain open to that. What has surprised me? I think the predictive power of some of the tests I mentioned just the implicit association test is one. This is a test that many listeners may be familiar with. It was developed by Tony Greenwald and Madhur Binajji and Brian Nosek and others.
Matthew K. Nock, Ph.D.:And it's a quick reaction time test. It's been on sixty minutes in 2020, and it was used to measure initially how people think about those of different races, white people and Black people, women and men, old people, young people, and so on. And I teamed up with Mahzarin Banaji in our department, one of the people who developed this test, and we developed a version of this that measured how people think about self injury and suicide. And it worked really well. And we brought it to the emergency department and people's reaction time to these different stimuli in milliseconds significantly predicted whether someone was going to make a suicide attempt or not above and beyond self report.
Matthew K. Nock, Ph.D.:So findings like this, where we take things from the lab and then bring them into the clinic, a lot of times they don't work. We did a version of the Stroop, the classic Stroop task. We got amazing results. It also predicted suicidal behavior in our initial study. One thing I love about science is the focus on replication.
Matthew K. Nock, Ph.D.:We did that study several more times, it didn't work. The first finding was a false positive with the implicit association test, that one has replicated repeatedly. It surprised me. Surprised me how well it works. We did another study where we turned a behavioral task like that on its head, and we used it to basically classically condition people to have an aversion to suicide.
Matthew K. Nock, Ph.D.:One of our postdocs did this study. It's an approach called evaluative conditioning. Just like classical conditioning, we did a little match game. We show people images of pill bottles, nooses, and that kind of thing. And we pair them with naturally aversive images, snakes, spiders, things that people are naturally, evolutionarily afraid of.
Matthew K. Nock, Ph.D.:And in a control condition, everyone sees these images, but they're not paired in the same way. And I won't bore you with the details of how we do the pairing. People who had suicide images, self injury images paired with naturally aversive images, they did this game for a month, Their self injurious behavior, their suicidal behavior decreased significantly. I didn't believe it. I said, Do it again.
Matthew K. Nock, Ph.D.:He did another study, same result. Did a third study, same result. We published it as a set of three studies. Unbelievable. The simple little matching game decreased suicidal behavior, this really difficult to treat outcome.
Matthew K. Nock, Ph.D.:So I'm surprised when anything that we do as researchers works and when the effect is replicated over and over again, especially for something really intransigent like suicide. So I'm surprised when anything works. When we get really nice findings like that and they're replicable, I get really excited because it represents progress towards treating this really difficult to treat behavior.
Tonya Ferraro:Have you had a research result? Have you seen a transition from, you have your result and then it changes practice or training or policy? What does that look Not
Matthew K. Nock, Ph.D.:really. As being a little critical, I guess a more optimistic answer is yes, we have some changes. I'm optimistic about the future, but I'm critical of our own research and the progress we've made, I want to see us make more. So sure, I've seen evidence based treatments develop over time, cognitive behavior therapy, dialectical behavior therapy. There have been studies over the past two decades, we've done some of them and been involved in some of them showing that things that we're doing are effective and we have effective treatments, but I think we should be trying to do a lot more.
Matthew K. Nock, Ph.D.:And I'm increasingly excited about, and we're increasingly doing implementation focused research, which also has some tricky ethical IRB issues of when does what we're doing cease being research and start being clinical practice. So a lot of our research So just describing research on the IAT, the implicit association test, this conditioning task, done in the lab. Most of our work now, 90%, is in clinics. So it's in emergency departments, it's in psychiatric inpatient units. It's trying to take the things we've developed and move them out into the field to see if we can start helping clinicians better identify which patients are at risk for suicide, start intervening with patients at high risk to see if we can drive risk down in real world settings.
Matthew K. Nock, Ph.D.:We're doing a lot with advances in technology, which I talked about in the meeting we were all at, where we're using smartphones and wearable sensors, monitoring people while they're at high risk for suicide to see, can we get better at identifying exactly when, what day, what week someone's going to make a suicide attempt, and then beam them with interventions in real time to try and keep them safe. So we're trying to get a lot better, a lot faster. So I guess to tie this all together, yes, we've seen progress, but for my money and as I get older, not nearly enough. I want us to make progress much faster. Doing this kind of work, again, raises ethical questions.
Matthew K. Nock, Ph.D.:I'm happy to dive into these if you all are interested. If we're following someone at risk for suicide, and the same is relevant for if you're following somebody with alcohol use or substance use or other kinds of episodic behaviors where harm is possible. How, where, when do we intervene? At what point, at what level, if someone has persistent thoughts of suicide, every day they have thoughts of suicide, and we're following them, let's say, for a month and sending them two, three, four, five surveys a day, quickie surveys on their phone, ask them about their mood and their anxiety and their thoughts of suicide, what do we do when someone says yes? Or if we give us a rating scale from zero to 10, at what point on the scale should we intervene?
Matthew K. Nock, Ph.D.:How should we intervene? Who should intervene? Is intervening harmful? What if we want to test different ways of intervening? We want to test, should we call someone on the phone?
Matthew K. Nock, Ph.D.:Should we have a chatbot interact with them? Should we use a large language model to interact with them? What if we want to do a randomized trial and test different ways of responding? Is it ethical in real time when someone's figuratively speaking or maybe literally speaking on the ledge and wanting to hurt themselves? Should we be experimenting in that space?
Matthew K. Nock, Ph.D.:All of these are questions that we wrestle with. They come up when we interact with IRBs around them, And they're great questions. I have my perspective on them, but that's just one perspective. I talk to IRBs and get their perspective and other researchers, people and clinicians have different levels of comfort with how much risk they're willing to tolerate and when they think we should intervene and how our university lawyers have their own perspective. They're more risk averse than the clinicians are, generally speaking, not always.
Matthew K. Nock, Ph.D.:And my job, as I see it, is to try and do right by humans and use the privileges that I've been granted as a researcher to try and do the best possible science that's going be most helpful to as many people as possible in our society. So that's my North Star, what is going to be advanced to science while being maximally helpful to society. Sorry, a lot of coffee today, not a lot of food. Try and pause and let you all say something.
Catherine Batsford:There with you. So the consent process, does it look different when there's an intervention potentially that could happen?
Matthew K. Nock, Ph.D.:We don't consent people. Kidding. IRB joke.
Catherine Batsford:Stop it.
Tonya Ferraro:I'm here for the IRB humor.
Matthew K. Nock, Ph.D.:, , promise not to throw in any six, seven references. I date this podcast. Yeah. The consent process is obviously very important for studies of suicide risk, and we're very clear in the process regarding what we're going to do, what we're not going to do, and when we're going to do it. So for instance, in our monitoring studies where we put smartphone apps on people's phones, who we recruit from the hospital because they've come to the hospital for high risk for suicide.
Matthew K. Nock, Ph.D.:We let them know, for instance, we're going to monitor the responses between 9AM and 9PM. And we'll do our best to respond if we think they're at imminent risk of hurting themselves. But they can't count on us to intervene. We can't promise that we're going to intervene. We can promise we will try to intervene.
Matthew K. Nock, Ph.D.:Our standard is we'll intervene within twenty four hours. In practice, our usual response time is more like twenty minutes. And we get real time pings when someone's above a certain threshold. We have a very detailed protocol for exactly what we do at each level of risk. But we want to be very clear with participants that this is not a minority report.
Matthew K. Nock, Ph.D.:We're not going to soop in and that you should not expect that we're going to be a clinical service and we're going to take steps to keep you safe. When we randomize people to If we're going to randomize people, we let them know that we're going to randomize them. We're going to test out different ways of whatever it is we're doing, intervening, responding, and so on. When we first started doing this monitoring work, we paused for a little while in the research because I asked my research team to pause because I wasn't quite sure what do we do at high levels of what is the standard? There's not a real standard in the field.
Matthew K. Nock, Ph.D.:This was a couple of years back, smartphones were sort of new. So we paused and we had a consensus meeting where we teamed up. I reached out to folks at National Institute of Mental Health and said, Hey, can we have a consensus meeting on this? And long story short, we convened a multiple day meeting where we had members of our IRB, our office of general counsel, researchers, folks from NIH, people from funding agencies, people with lived experience, people who have experienced suicidal thoughts, to come together for a few days and talk about, well, what should the standards be? And we ended up publishing a paper on this that folks can access.
Matthew K. Nock, Ph.D.:It's about the consensus statement on ethical conduct of research with people at high risk for suicide. And we came to a consensus on, here are the things you should do in the consent process. For instance, people should know the nature of the study. They should know when we're going to intervene and how. We should collect information from collaterals.
Matthew K. Nock, Ph.D.:So if we can't reach them and we know they're hired for suicide, there's someone that they've identified that we can reach out to to take steps to keep them safe and so on and so on. We should be very clear about what our practices are for at what threshold we're going to intervene, how and when and who's going follow-up and so on. I won't drone on and on, but we talked through for days what the different aspects of responding to people at high risk for suicide in research studies should be. And now we use that as a guide. And that was published in 2021, I believe, in a couple of years now.
Matthew K. Nock, Ph.D.:We're interested in updating that to see now should we update those standards. So we're very careful and trying to be very clear with participants, with IRBs, and follow things as closely as we possibly can. And when we bump up against questions that we think will be enhanced with research, we propose studies to do experiments to see, is it harmful or helpful? Is this harmful or helpful? Is this effective?
Matthew K. Nock, Ph.D.:Does this drive down risk? One big question we're focused on now is when someone's at very high risk for suicide by their own statement, I'm having thoughts of suicide. I think I'm going to act on my suicidal thoughts. Is it more effective to call them? Should a human call them?
Matthew K. Nock, Ph.D.:Or should we have an interactive sort of auto tool or chatbot, if you will, interact with them? Most people might say, Well, you should have a human call them. Why I think this is an important research question is when we call them, when we as humans call them, it often takes longer to reach them than an automated tool would take. If someone says, 10 out of 10 is my thought of suicide, the severity of my thoughts or my intention to act, a tool, a chatbot, could pop up right away and do the same risk assessment that we would do when we get them on the phone twenty minutes later. That twenty minutes could be an important gap.
Matthew K. Nock, Ph.D.:A lot of times, I can say anecdotally, and we've done these kinds of studies with over a thousand participants so far, we'll call somebody and they'll say, I'm a teacher and I'm at school right now. Yes, I'm having thoughts of suicide as I live my daily life, but now's not a good time to talk to you. So we're doing studies on this to see if we randomly assign someone at different levels of risk to different kinds of intervention, can we learn what is the most effective intervention at that level of risk? And maybe it varies across people, and maybe it varies within people over time. So maybe if I'm with someone else, calling me is not the best thing to do.
Matthew K. Nock, Ph.D.:But if I'm by myself, then maybe calling me is a better thing to do. So we're trying to increasingly build better precision in our experiments and in our interventions.
Tonya Ferraro:I just want to take a moment to really appreciate that you took a pause in your research, right? Because I think when you're part of a project and it always feels behind something, right? And I think it's just amazing that you said, Wait a second, we're going to look into this. And it is all the pause is part of the process. Because I think when you're in the research and you're so close to it, it can feel like you can't take that moment for anything.
Tonya Ferraro:So I just want to acknowledge that and just, I really appreciate that you did this full sub study and it contributes to the bigger goal. But yeah, I just really love that.
Matthew K. Nock, Ph.D.:Yeah, thank you. It is anxiety provoking when we do always feel behind. At the same time, this is real life stuff. And statistically speaking, given the scope of this problem, all of us on this call, all of the folks listening have been touched by suicide in some way. Fifteen percent of people in The US say that they've seriously considered suicide at some point in their life.
Matthew K. Nock, Ph.D.:Five percent of people have made a suicide attempt. So all of us probably know somebody who has had thoughts of suicide or made a suicide attempt or died by suicide in our family, among our friends, and so on. So this is real, and I have as well. And so I feel tremendous responsibility to make sure that we're doing this right and we're not rushing anything. And I know that researchers vary in their level of comfort.
Matthew K. Nock, Ph.D.:And some folks will be more conservative than me. If we draw a line at just making up an arbitrary scale, we use a zero to 10 scale. If someone's risk is, let's say eight, nine, or 10 out of 10, that's where we draw a threshold at eight. Anybody who's above 80% risk will intervene, whatever that means. We've had clinicians say, why 80%?
Matthew K. Nock, Ph.D.:Why not 50%? More likely than not, shouldn't you intervene there? Well, that becomes practically, I think, not very feasible. Some clinicians, some researchers will say, we're not going to intervene at all. We're just going to follow people over time and see when people make a suicide attempt or die by suicide.
Matthew K. Nock, Ph.D.:If you intervene, you're affecting nature in some way. And it's no longer an observational study. Now it becomes more of an intervention study. So let's just let people behave, and we'll monitor it over time. For me, that feels like not enough.
Matthew K. Nock, Ph.D.:I often think of during our consensus meeting, someone said poignantly, what if this was your child in the study? What if this was your spouse or your sibling or your parent? What would you want the research team to do? And that really stuck with me. That's why, to me, another north star is, what if this was my kid?
Matthew K. Nock, Ph.D.:What if this was my spouse? What if this is my sibling? What would I want a researcher to do? If you knew that my child said 10 out of 10, I'm going kill myself, and you sat and waited and watched to see what happened, I would have a big problem with that. At the same time, someone may have a problem with us using our made up eight.
Matthew K. Nock, Ph.D.:Someone might say, why not five? That to me, based on the date that we looked at data and it's how we picked the threshold and so on, it's the best we can think to do given the resources we have and given the data we have. So we stand behind it. But I think very, very careful about each little aspect of this because we want to get it right. We want to make the science as strong as possible while doing all we can to keep people safe.
Matthew K. Nock, Ph.D.:And I'm, for one, happy to mess up our methodology and publish a weaker study, but try and save a few lives or help keep people safe if we can, I'll take that 10 times out of 10, I'll take that calculus. Absolutely. And it does. We had an instance last week where we're monitoring someone and they made a suicide attempt and we were able to locate them and get them to services and they had taken an overdose and we got them to the hospital and they followed up and now they're safe and so on. And that happens from time to time in our studies.
Matthew K. Nock, Ph.D.:And it's nice that along the way, we can try and, in addition to doing the research, try and intervene and help people. And the hope is that we develop a system that then gets implemented and helps many more people. The goal of the research is not just advancing the science, but again, trying to improve health and human functioning.
Catherine Batsford:How do you roll people off a study safely?
Matthew K. Nock, Ph.D.:Yeah, that's a good question. Very carefully and part of the consent process as well. And we have debriefings at the end. We usually have qualitative interviews and talk to people about what they liked about the study, what they didn't like about the study, and so on. We make very clear when the study is ending and that we're not monitoring people anymore and take the apps off their phone and so on.
Matthew K. Nock, Ph.D.:What gets tough is, this happens especially with parents when we're following adolescence. I'm a parent of three kids, so I empathize. We enroll kids who are at risk for suicidal behavior and we're monitoring them. One study we do, we monitor kids for six months after they leave a psychiatric hospitalization, which is an especially high risk time. And we're building statistical models that are getting increasingly accurate at telling us when people are at risk, which is great.
Matthew K. Nock, Ph.D.:In the study, let's say we'll use this eight out of ten again, a kid says, I'm having thoughts of suicide. I think I'm going to act on them. Our protocol says we call the parents and we then talk to the child and we have a risk assessment we follow and we keep them safe. Parents generally like this, not all the time, but most parents like this extra set of eyes on their at risk child helping to keep them safe. It does happen that at the end of the study, some parents will say, Can we keep this going?
Matthew K. Nock, Ph.D.:Because this is helpful, I want this extra set of eyes, and we can't. We have to stop, it's a six month study, this is the end of the study. So it's tough, but we have to follow the protocol, we're very upfront about it, we're very clear about it, and we stick to it. But for me, also highlights potential clinical utility of the work that this could be with the tools which would have clinical use down the road, we think. It might help keep people safe and keep kids safe, and provide a way of monitoring people at risk for not just suicide, but again, alcohol use, drug use, eating disorder behaviors, and so on.
Matthew K. Nock, Ph.D.:And I see this as a potential positive use of new technology. A lot of us wring our hands about, understandably and appropriately perhaps, how much kids are using technology and how potentially harmful it is. I think there's some helpful aspects as well, like having an extra set of eyes on helpful, caring, supportive eyes on what our kids are doing and trying to provide help when they need it. Because I don't think our traditional forms of care, come see me once a week and talk to me for fifty minutes about what you're doing and thinking and feeling, I don't think that's sufficient, and the data is not sufficient for treating something like suicidal thoughts and behaviors. So I think something that, and we know from our monitoring studies that suicidal thoughts ebb and flow hour by hour, day by day.
Matthew K. Nock, Ph.D.:So having technologies that can respond to that and reach people and provide treatment in the moment, I think is gonna be a really valuable step. And just figuring out how to do that ethically and effectively and in ways that aren't intrusive.
Catherine Batsford:So I had a question, how do you take care
Matthew K. Nock, Ph.D.:of
Catherine Batsford:yourselves? This is incredibly heart wrenching, important work.
Matthew K. Nock, Ph.D.:Yeah, it's a good question. We talk a lot on our research team about self care. It's a great group. Our research team is about 30 people, staff. We have currently eight PhD students, close to 10 postbac research assistants, some undergraduates.
Matthew K. Nock, Ph.D.:It's a good, friendly, funny, caring group of people, which might sound weird given the heavy nature of what we're studying, but I think important to try and create and maintain a really good, healthy, functional, supportive team. And we do have cases of suicide attempt. We have lost participants to suicide in the natural course of the illness, the condition, I always remind myself and I remind our team that this is why we're doing what we do, in the same way that oncology researchers lose patients to We need to do better. Even at our best, at Harvard and a team that's been doing this for two decades, we can't predict this nearly as well as we want. We can't prevent it nearly as well as we want.
Matthew K. Nock, Ph.D.:And it hurts and it affects us as it affects everyone. A lot of folks on our team have talked openly about they've lost someone to suicide or so. So it's personal for a lot of us and we need to do better. And this is how we do better, is advancing the science and advancing clinical practice. Just like cancer is not going to stop on its own, suicide not going to stop on its own.
Matthew K. Nock, Ph.D.:From my mind, who better than psychologists, psychiatrists, mental health researchers, IRBs, to try and study this problem and get better and better at preventing it? And of course, using all the things that we teach patients, the distraction and self soothing. I have an old Jeep that I drive and work on and have two motorcycles, I like to run and lie on the floor and play with my kids and hang out with my wife and watch housewives of whatever city it's on. Sometimes I just like to shut it all off at night and something non academic and mindless.
Tonya Ferraro:I'm curious, you've been in your career for a while, you mentor students. I like to ask the what I wish I knew question when you started out. What no one told you but what you maybe wish you knew back then and maybe what you share with mentees now.
Matthew K. Nock, Ph.D.:What did I wish I knew? I wish I knew how free this career is, how fun it is, how perpetually new it is. For instance, I met up with a friend from college maybe a year ago, and he came by our lab and said, Wow, you work with young people. I've been working with the same five people since college, and we were all 20, and now we're all in our 50s, and it's the same people. And they're great.
Matthew K. Nock, Ph.D.:But this career, there's a constant changing of the guard, there's new students coming in, new young researchers coming in, sometimes new IRB members coming in. And it's amazing, it's wonderful. And with that comes mentorship. I didn't think at all about mentorship when I got into the field, perhaps naively. I was thinking about science and here's the questions that I have and I'm so passionate about them.
Matthew K. Nock, Ph.D.:And then I started working with students more actively as a faculty person. I thought, wow, this is amazing. You work with someone and then they develop their ideas and they implement them and they get results and they present it and they publish it. Then they start a research lab and then they have students. I don't mean this in a condescending way to the students.
Matthew K. Nock, Ph.D.:It feels like children. They're growing up and you see them develop and become mature scientists, mature professionals. It's my favorite part of the job. I love it. And I didn't know, couldn't get my head around that it would be such a big enjoyable part of this profession.
Matthew K. Nock, Ph.D.:But I really, really loved it. That doesn't help anybody, early career. So sorry, I think that's probably the purpose of your question. I missed it. But that's what comes to mind.
Matthew K. Nock, Ph.D.:It's just, it's, I really, really love the mentorship process and just seeing people do really well and seeing people have ideas that I could never be smart enough to come up with and implement them in ways that I could never implement them gives me a lot of hope for the field.
Catherine Batsford:So on the flip side, I'm a new IRB member. I've got some of these studies coming across. What questions should I be asking? What should I be reassured by? What should I be looking for?
Catherine Batsford:How can you help me understand the work that you're trying to get done?
Matthew K. Nock, Ph.D.:That's a great question. I would encourage IRB members to I'm a big fan of This is not an exciting answer. Communication. Reach out to researchers. The researchers whose studies you're reviewing, ask them lots of questions.
Matthew K. Nock, Ph.D.:I routinely am asked by IRBs to provide feedback, guidance. As an exclusive expert, what do I think about x, y, z? And is this done up to the standards in the field and so on? Information is power. I would say reach out to do as much outreach as you can to try and get to the heart of things and use the regulations as a guide and communicate in both directions.
Matthew K. Nock, Ph.D.:Get information about what they're doing and also communicate back the regulations. Think just the more researchers understand what IRBs are doing and why they're doing it, the easier it all is. Think things become more collaborative and more helpful more easily. I think this comes back to something I said at the very start. If we're each operating from this hostile attribution position of, don't really want to I'm going to say as little as possible in my IRB application so you don't know what I'm doing and you're going to find out and we're not really talking to each other.
Matthew K. Nock, Ph.D.:That's a recipe for disaster in my book. Think the more open we are as researchers, the more open the IRB is, what do you want to know, why do you want to know it, the better. So I think just ask lots of questions of the researcher, of experts, and be as transparent as you're comfortable and able to be.
Catherine Batsford:Fantastic. Tania, do you have any more questions?
Tonya Ferraro:I think I'm okay. Good. Yeah, this has been great. I've loved it.
Matthew K. Nock, Ph.D.:Amazing talking to both of you. Sorry for rambling. No. No. Talked forever about all of this stuff.
Catherine Batsford:We can listen forever.
Matthew K. Nock, Ph.D.:Unless I'm stopped, I'll go on and on.
Catherine Batsford:It's fascinating. I think we always try and leave on a I don't know if it's a positive note, but you had mentioned in your session at the conference that suicide rates haven't changed over time per se. And I would love to have you speak about that for a minute because I found that very reassuring in some way and not.
Matthew K. Nock, Ph.D.:Yeah. Yeah. So I guess a source of pessimism about suicide or optimism, depending on, I guess, glass half empty, half full, people talk a lot. We hear a lot about, well, suicide rate has increased dramatically in the past twenty years. It has, but it decreased to twenty years before that, literally.
Matthew K. Nock, Ph.D.:And the suicide rate now is the same. It's virtually identical to what it was one hundred years ago. So is that good? Is that bad? Well, hasn't increased overall, but it also hasn't decreased overall.
Matthew K. Nock, Ph.D.:I think the pessimistic position here is if you look at most other leading causes of death and you look at the mortality rate for them over the past one hundred years, cancers, pneumonia, accidents, HIVAIDS, they've all dropped precipitously. The mortality rate has dropped. Suicide hasn't, so that's the pessimistic view. The optimistic view is, well, why have they dropped? It's because science has advanced in And each of these we've seen the results of science get implemented.
Matthew K. Nock, Ph.D.:Medical practice has changed. We've got much more effective treatments for cancer. The seatbelt wearing campaign has been tremendously helpful for decreasing motor vehicle accident deaths, HIVAID treatments, more recently COVID treatments and so on. So that's optimistic. This hasn't yet happened for suicide, but I'm optimistic because if you look at just the past five, ten years, our ability to identify who's at risk, to predict when that risk increases is gonna increase, to deliver effective treatments has all dramatically improved in the past decade or so.
Matthew K. Nock, Ph.D.:And the number of people studying suicide has increased dramatically. So I see stakes increasing, I see more research funding, not enough, but more research funding being allocated to study suicide and more people entering this field. So I'm optimistic for the future of suicide prevention. I hesitate to not end on a super positive note. I'm anxious about the current funding environment and the federal removal of for all of science.
Matthew K. Nock, Ph.D.:But from my perspective, we've got to stay focused on our mission. We've got to keep the ship on the water. We've got to keep, as I said earlier, suicide's not going to resolve it. This is a bipartisan, nonpartisan issue. All of us don't want to struggle with suicidal thoughts, lose loved ones to suicide.
Matthew K. Nock, Ph.D.:So I'm hopeful that we can all work together and find a way, not just researchers and IMB members, but members of government, members of NIH, philanthropists, corporations, industry partners, we can all work together to try and really turn the tide on suicide, to try and prevent this really devastating loss of life that, again, disproportionately takes our young people. So I think there's reasons to be pessimistic, but overall, I'm much more optimistic and I see a fundamental improvement in science in this area. I hope and believe things are going to continue to get better.
Tonya Ferraro:Wonderful. Well, I feel like you're speaking to this point of it's not an IRB question, but research is a public good. There is a cost to not doing research at the end of the day, a huge cost. And I think that that's such an important thing to especially during this tenuous time.
Matthew K. Nock, Ph.D.:Yeah, there is a real cost. And it's health and it's years of life lost. Suicide is the fourth leading contributor to years of potential life lost because it affects young people disproportionately. We can calculate what the impact of suicide is. We can calculate over time what the impact of enhanced funding or decreased funding is.
Matthew K. Nock, Ph.D.:We're not going to see it right away. We're not going see the impact right away. We'll it over time, as we will with cancer, as we will with heart disease and so on. So, it's in all of our interests to keep working on advancing science, advancing practice. For me, there's not a need to get political here, but there is a need to highlight the importance
Catherine Batsford:the work.
Matthew K. Nock, Ph.D.:The importance of the work, the costs and the benefits. And I Polling data suggests everybody is for suicide prevention. Not every single person perhaps, but virtually everybody does not want their loved ones to die, does not want their loved ones to suffer. So this is why I'm optimistic that we're going to find a way to work together to keep doing this kind of research. And other kinds of research, same with, again, alcohol use, substance use.
Matthew K. Nock, Ph.D.:We don't want each other to be suffering. And it's incumbent upon us as a society, as scientists, as IRB members, to find ways to work together to keep this kind of work moving forward.
Catherine Batsford:Wonderful. Well
Matthew K. Nock, Ph.D.:We'll do it. We will do it. Am optimistic.
Catherine Batsford:And we'll keep telling people about it.
Matthew K. Nock, Ph.D.:And thanks again for focusing on this. We said at the top, as we say in the business, it's often not a topic people lean into or choose to focus on. So I am deeply grateful that you all at PRIM&R invited me to speak at the meeting and that you followed up with focusing on this often difficult topic on the podcast. Shining a light on difficult topics is the best way to have an impact and to decrease stigma and to do a lot of the things that we're talking about. So thank you for doing this.
Catherine Batsford:Yeah. Well, thank you.